- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.86 / $239.86 / $266.25
| Facility | | $239.86 | $239.86 | $266.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.86 / $239.86 / $266.25
| Professional | | $239.86 | $239.86 | $266.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.86 / $263.38 / $263.38
| Facility | | $145.86 | $263.38 | $263.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.38 / $263.38 / $263.38
| Professional | | $263.38 | $263.38 | $263.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $20.00 / $20.00
| Professional | | $20.00 | $20.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.16 / $261.26 / $282.19
| Professional | | $235.16 | $261.26 | $282.19 |