- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.40 / $175.40 / $175.40
| Facility | | $175.40 | $175.40 | $175.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.29 / $175.40 / $175.40
| Professional | | $173.29 | $175.40 | $175.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.25 / $272.00 / $561.00
| Professional | | $219.25 | $272.00 | $561.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $351.02 / $351.02 / $351.02
| Facility | | $351.02 | $351.02 | $351.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.85 / $285.47 / $377.10
| Professional | | $82.85 | $285.47 | $377.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.67 / $73.67 / $175.40
| Professional | | $73.67 | $73.67 | $175.40 |