- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.60 / $208.60 / $208.60
| Facility | | $208.60 | $208.60 | $208.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.60 / $236.36 / $236.36
| Professional | | $208.60 | $236.36 | $236.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.20 / $236.97 / $278.79
| Professional | | $235.20 | $236.97 | $278.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.88 / $292.88 / $366.09
| Professional | | $292.88 | $292.88 | $366.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.27 / $208.60 / $625.79
| Facility | | $206.27 | $208.60 | $625.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.60 / $389.86 / $450.22
| Professional | | $208.60 | $389.86 | $450.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.27 / $369.22 / $450.22
| Professional | | $226.27 | $369.22 | $450.22 |