- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.59 / $208.59 / $208.59
| Facility | | $208.59 | $208.59 | $208.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.70 / $208.59 / $208.59
| Professional | | $119.70 | $208.59 | $208.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.00 / $272.00 / $272.00
| Professional | | $272.00 | $272.00 | $272.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.68 / $210.68 / $210.68
| Facility | | $210.68 | $210.68 | $210.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.80 / $210.68 / $217.00
| Professional | | $153.80 | $210.68 | $217.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.13 / $136.94 / $259.97
| Professional | | $95.13 | $136.94 | $259.97 |