- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.41 / $238.41 / $238.41
| Professional | | $238.41 | $238.41 | $238.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.60 / $300.60 / $300.60
| Facility | | $300.60 | $300.60 | $300.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.05 / $300.60 / $300.60
| Professional | | $101.05 | $300.60 | $300.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.60 / $300.60 / $300.60
| Facility | | $300.60 | $300.60 | $300.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.58 / $186.58 / $300.60
| Professional | | $186.58 | $186.58 | $300.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.07 / $87.07 / $207.31
| Professional | | $87.07 | $87.07 | $207.31 |