- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $216.76 / $216.76 / $216.76
| Facility | | $216.76 | $216.76 | $216.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.61 / $134.69 / $216.76
| Professional | | $102.61 | $134.69 | $216.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.00 / $160.00 / $160.00
| Professional | | $160.00 | $160.00 | $160.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.55 / $152.55 / $239.05
| Facility | | $152.55 | $152.55 | $239.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.36 / $152.55 / $209.32
| Professional | | $111.36 | $152.55 | $209.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.02 / $106.53 / $165.07
| Professional | | $71.02 | $106.53 | $165.07 |