- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.28 / $175.28 / $175.28
| Facility | | $175.28 | $175.28 | $175.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.28 / $175.28 / $175.28
| Professional | | $175.28 | $175.28 | $175.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.37 / $145.36 / $159.10
| Professional | | $123.37 | $145.36 | $159.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.25 / $141.65 / $178.12
| Professional | | $140.25 | $141.65 | $178.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.28 / $175.28 / $324.27
| Facility | | $175.28 | $175.28 | $324.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.32 / $178.95 / $178.95
| Professional | | $150.32 | $178.95 | $178.95 |