- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.36 / $177.36 / $177.36
| Facility | | $177.36 | $177.36 | $177.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.36 / $177.36 / $177.36
| Professional | | $177.36 | $177.36 | $177.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.75 / $185.75 / $185.75
| Professional | | $185.75 | $185.75 | $185.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.97 / $160.97 / $160.97
| Professional | | $160.97 | $160.97 | $160.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.28 / $216.28 / $660.51
| Professional | | $216.28 | $216.28 | $660.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.67 / $166.00 / $235.17
| Professional | | $110.67 | $166.00 | $235.17 |