- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.04 / $440.04 / $440.04
| Facility | | $440.04 | $440.04 | $440.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.08 / $106.39 / $112.51
| Professional | | $95.08 | $106.39 | $112.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.00 / $80.00 / $80.00
| Facility | | $80.00 | $80.00 | $80.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.00 / $82.27 / $193.97
| Professional | | $77.00 | $82.27 | $193.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.55 / $107.05 / $274.26
| Professional | | $67.55 | $107.05 | $274.26 |