- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.50 / $188.50 / $197.30
| Facility | | $188.50 | $188.50 | $197.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.50 / $188.50 / $208.24
| Professional | | $188.50 | $188.50 | $208.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.00 / $511.00 / $841.00
| Professional | | $511.00 | $511.00 | $841.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.70 / $284.70 / $600.02
| Professional | | $284.70 | $284.70 | $600.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.59 / $363.60 / $656.10
| Professional | | $184.59 | $363.60 | $656.10 |