- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.70 / $206.70 / $206.70
| Facility | | $206.70 | $206.70 | $206.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.70 / $206.70 / $206.70
| Professional | | $206.70 | $206.70 | $206.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.28 / $146.28 / $146.28
| Professional | | $146.28 | $146.28 | $146.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.00 / $78.00 / $78.00
| Professional | | $78.00 | $78.00 | $78.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.30 / $223.29 / $372.15
| Facility | | $156.30 | $223.29 | $372.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.00 / $234.00 / $327.60
| Professional | | $234.00 | $234.00 | $327.60 |