- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.40 / $247.40 / $247.40
| Professional | | $247.40 | $247.40 | $247.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.83 / $170.83 / $170.83
| Facility | | $170.83 | $170.83 | $170.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.21 / $170.83 / $175.95
| Professional | | $145.21 | $170.83 | $175.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.71 / $247.40 / $258.39
| Facility | | $243.71 | $247.40 | $258.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $221.94 / $247.40 / $258.39
| Facility | | $221.94 | $247.40 | $258.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.21 / $170.83 / $175.95
| Professional | | $145.21 | $170.83 | $175.95 |