- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $660.69 / $660.69
| Facility | | $141.25 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $154.88 / $281.84
| Professional | | $93.33 | $154.88 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $177.83 / $177.83
| Professional | | $109.65 | $177.83 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $165.96 / $302.00
| Professional | | $63.10 | $165.96 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $128.82 / $263.03
| Professional | | $53.70 | $128.82 | $263.03 |