- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.74 / $210.74 / $210.74
| Facility | | $210.74 | $210.74 | $210.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $200.00
| Professional | | $150.00 | $150.00 | $200.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.62 / $178.70 / $240.41
| Facility | | $147.62 | $178.70 | $240.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.18 / $127.73 / $229.12
| Facility | | $78.18 | $127.73 | $229.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.37 / $50.37 / $50.37
| Professional | | $50.37 | $50.37 | $50.37 |