- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.61 / $104.48 / $104.48
| Facility | | $80.61 | $104.48 | $104.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.58 / $80.61 / $80.61
| Professional | | $63.58 | $80.61 | $80.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.40 / $506.40 / $506.40
| Professional | | $506.40 | $506.40 | $506.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.45 / $67.45 / $67.45
| Professional | | $67.45 | $67.45 | $67.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.61 / $86.25 / $117.59
| Facility | | $80.61 | $86.25 | $117.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.83 / $461.83 / $461.83
| Professional | | $461.83 | $461.83 | $461.83 |