- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $405.74 / $405.74 / $405.74
| Facility | | $405.74 | $405.74 | $405.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.07 / $405.74 / $405.74
| Professional | | $192.07 | $405.74 | $405.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.83 / $334.83 / $334.83
| Professional | | $334.83 | $334.83 | $334.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.27 / $218.27 / $337.40
| Facility | | $218.27 | $218.27 | $337.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.34 / $218.27 / $333.47
| Professional | | $159.34 | $218.27 | $333.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.22 / $186.87 / $271.31
| Professional | | $112.22 | $186.87 | $271.31 |