- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.63 / $155.63 / $155.63
| Facility | | $155.63 | $155.63 | $155.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.44 / $487.50 / $646.41
| Professional | | $224.44 | $487.50 | $646.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.00 / $165.00 / $165.00
| Professional | | $165.00 | $165.00 | $165.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.89 / $318.89 / $532.44
| Facility | | $318.89 | $318.89 | $532.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.53 / $657.30 / $657.30
| Professional | | $623.53 | $657.30 | $657.30 |