- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $288.40
| Facility | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $128.82 / $223.87
| Professional | | $77.62 | $128.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $128.82
| Professional | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $123.03 / $275.42
| Professional | | $53.70 | $123.03 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.15 / $117.49 / $186.21
| Professional | | $37.15 | $117.49 | $186.21 |