- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.07 / $217.07 / $217.07
| Facility | | $217.07 | $217.07 | $217.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.52 / $217.07 / $217.07
| Professional | | $210.52 | $217.07 | $217.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.85 / $146.85 / $146.85
| Facility | | $146.85 | $146.85 | $146.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.90 / $308.33 / $448.59
| Professional | | $208.90 | $308.33 | $448.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.07 / $264.45 / $459.31
| Facility | | $217.07 | $264.45 | $459.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.16 / $253.50 / $404.10
| Professional | | $204.16 | $253.50 | $404.10 |