- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $444.68 / $444.68 / $444.68
| Facility | | $444.68 | $444.68 | $444.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $173.03 / $208.79
| Professional | | $173.03 | $173.03 | $208.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.00 / $174.00 / $174.00
| Facility | | $174.00 | $174.00 | $174.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $173.03 / $173.03
| Professional | | $173.03 | $173.03 | $173.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $184.79 / $380.67
| Professional | | $173.03 | $184.79 | $380.67 |