- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $261.14 / $261.14 / $261.14
| Facility | | $261.14 | $261.14 | $261.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.14 / $261.14 / $261.14
| Professional | | $261.14 | $261.14 | $261.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.49 / $269.49 / $269.49
| Professional | | $269.49 | $269.49 | $269.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.56 / $362.72 / $362.72
| Facility | | $307.56 | $362.72 | $362.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.59 / $271.89 / $288.74
| Professional | | $228.59 | $271.89 | $288.74 |