- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.46 / $217.46 / $217.46
| Facility | | $217.46 | $217.46 | $217.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.97 / $217.46 / $217.46
| Professional | | $103.97 | $217.46 | $217.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.40 / $225.00 / $343.12
| Professional | | $14.40 | $225.00 | $343.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.70 / $279.26 / $451.85
| Facility | | $54.70 | $279.26 | $451.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.46 / $217.46 / $611.05
| Facility | | $217.46 | $217.46 | $611.05 |