- 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
- $94.51 / $217.46 / $400.50
| Professional | | $94.51 | $217.46 | $400.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.98 / $190.13 / $308.25
| Facility | | $100.98 | $190.13 | $308.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.23 / $270.23 / $270.23
| Professional | | $270.23 | $270.23 | $270.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.00 / $225.00 / $225.00
| Professional | | $225.00 | $225.00 | $225.00 |