- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.53 / $215.53 / $215.53
| Facility | | $215.53 | $215.53 | $215.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.53 / $215.53 / $215.53
| Professional | | $215.53 | $215.53 | $215.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.19 / $270.19 / $270.19
| Professional | | $270.19 | $270.19 | $270.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.10 / $194.10 / $194.10
| Professional | | $194.10 | $194.10 | $194.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.83 / $262.83 / $802.69
| Professional | | $262.83 | $262.83 | $802.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.49 / $201.73 / $306.88
| Professional | | $134.49 | $201.73 | $306.88 |