- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.26 / $309.26 / $309.26
| Facility | | $309.26 | $309.26 | $309.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.60 / $301.60 / $309.26
| Professional | | $301.60 | $301.60 | $309.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.10 / $238.10 / $238.10
| Professional | | $238.10 | $238.10 | $238.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.77 / $324.72 / $1,577.08
| Facility | | $294.77 | $324.72 | $1,577.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.68 / $246.61 / $304.98
| Professional | | $187.68 | $246.61 | $304.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.68 / $246.61 / $303.70
| Professional | | $187.68 | $246.61 | $303.70 |