- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.18 / $195.18 / $195.18
| Facility | | $195.18 | $195.18 | $195.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.18 / $195.18 / $195.18
| Professional | | $195.18 | $195.18 | $195.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.25 / $360.25 / $360.25
| Professional | | $360.25 | $360.25 | $360.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.53 / $277.67 / $317.33
| Facility | | $255.53 | $277.67 | $317.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.94 / $118.94 / $148.68
| Professional | | $118.94 | $118.94 | $148.68 |