- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.32 / $307.32 / $307.32
| Facility | | $307.32 | $307.32 | $307.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.47 / $307.32 / $307.32
| Professional | | $145.47 | $307.32 | $307.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.75 / $225.75 / $225.75
| Professional | | $225.75 | $225.75 | $225.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.91 / $189.91 / $343.76
| Facility | | $189.91 | $189.91 | $343.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.63 / $189.91 / $301.00
| Professional | | $138.63 | $189.91 | $301.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.08 / $161.76 / $243.87
| Professional | | $101.08 | $161.76 | $243.87 |