- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.16 / $238.16 / $346.05
| Facility | | $238.16 | $238.16 | $346.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.16 / $346.05 / $346.05
| Professional | | $238.16 | $346.05 | $346.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.15 / $238.16 / $396.27
| Facility | | $106.15 | $238.16 | $396.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.16 / $274.02 / $346.05
| Professional | | $238.16 | $274.02 | $346.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.60 / $164.42 / $274.02
| Professional | | $148.60 | $164.42 | $274.02 |