- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $243.71
| Facility | | $243.71 | $243.71 | $243.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $247.40
| Professional | | $243.71 | $243.71 | $247.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $265.48 / $278.75
| Facility | | $90.00 | $265.48 | $278.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.66 / $265.48 / $265.48
| Professional | | $225.66 | $265.48 | $265.48 |
- 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 / $170.83
| Professional | | $145.21 | $170.83 | $170.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $90.00 / $100.00
| Facility | | $90.00 | $90.00 | $100.00 |