- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.56 / $147.56 / $147.56
| Facility | | $147.56 | $147.56 | $147.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.29 / $147.56 / $183.71
| Professional | | $124.29 | $147.56 | $183.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.89 / $182.89 / $182.89
| Facility | | $182.89 | $182.89 | $182.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $739.00
| Professional | | $141.06 | $141.06 | $739.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.86 / $233.77 / $302.45
| Professional | | $143.86 | $233.77 | $302.45 |