- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.54 / $247.54 / $247.54
| Facility | | $247.54 | $247.54 | $247.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.94 / $247.54 / $256.14
| Professional | | $211.94 | $247.54 | $256.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.10 / $287.10 / $312.51
| Professional | | $287.10 | $287.10 | $312.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.54 / $247.54 / $247.54
| Facility | | $247.54 | $247.54 | $247.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.63 / $247.54 / $247.54
| Professional | | $241.63 | $247.54 | $247.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |