- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.32 / $211.32 / $239.86
| Facility | | $211.32 | $211.32 | $239.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.86 / $239.86 / $239.86
| Professional | | $239.86 | $239.86 | $239.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.87 / $239.87 / $239.87
| Professional | | $239.87 | $239.87 | $239.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.38 / $263.38 / $263.38
| Facility | | $263.38 | $263.38 | $263.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.96 / $172.96 / $172.96
| Professional | | $172.96 | $172.96 | $172.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.81 / $265.73 / $338.63
| Professional | | $232.81 | $265.73 | $338.63 |