- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.28 / $181.28 / $181.28
| Facility | | $181.28 | $181.28 | $181.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.18 / $181.28 / $181.28
| Professional | | $144.18 | $181.28 | $181.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.49 / $190.36 / $512.70
| Professional | | $161.49 | $190.36 | $512.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.52 / $189.50 / $512.70
| Professional | | $116.52 | $189.50 | $512.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.46 / $196.03 / $340.24
| Professional | | $175.46 | $196.03 | $340.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.16 / $194.62 / $621.23
| Professional | | $175.16 | $194.62 | $621.23 |