- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.03 / $230.03 / $230.03
| Facility | | $230.03 | $230.03 | $230.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.82 / $230.03 / $230.03
| Professional | | $116.82 | $230.03 | $230.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.42 / $220.42 / $220.42
| Professional | | $220.42 | $220.42 | $220.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.00 / $170.64 / $272.94
| Facility | | $108.00 | $170.64 | $272.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.57 / $170.64 / $239.00
| Professional | | $124.57 | $170.64 | $239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.08 / $136.51 / $205.43
| Professional | | $80.08 | $136.51 | $205.43 |