- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.36 / $213.36 / $213.36
| Facility | | $213.36 | $213.36 | $213.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.36 / $213.36 / $213.36
| Professional | | $213.36 | $213.36 | $213.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.40 / $223.42 / $649.72
| Professional | | $218.40 | $223.42 | $649.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $495.59 / $495.59 / $495.59
| Professional | | $495.59 | $495.59 | $495.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.00 / $351.92 / $656.62
| Professional | | $206.00 | $351.92 | $656.62 |