- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.45 / $273.45 / $273.45
| Facility | | $273.45 | $273.45 | $273.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.45 / $273.45 / $273.45
| Professional | | $273.45 | $273.45 | $273.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.25 / $360.25 / $360.25
| Professional | | $360.25 | $360.25 | $360.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $277.67 / $317.33 / $526.67
| Facility | | $277.67 | $317.33 | $526.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.00 / $167.00 / $167.00
| Professional | | $167.00 | $167.00 | $167.00 |