- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.47 / $204.47 / $204.47
| Facility | | $204.47 | $204.47 | $204.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.47 / $204.47 / $204.47
| Professional | | $204.47 | $204.47 | $204.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $452.37 / $452.37 / $452.37
| Facility | | $452.37 | $452.37 | $452.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.00 / $408.72 / $613.79
| Professional | | $315.00 | $408.72 | $613.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.55 / $198.55 / $204.47
| Facility | | $198.55 | $198.55 | $204.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.44 / $379.57 / $495.83
| Professional | | $232.44 | $379.57 | $495.83 |