- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.26 / $230.26 / $230.26
| Facility | | $230.26 | $230.26 | $230.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $230.26
| Professional | | $230.15 | $230.15 | $230.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.07 / $268.32 / $268.32
| Professional | | $228.07 | $268.32 | $268.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.13 / $217.13 / $217.13
| Facility | | $217.13 | $217.13 | $217.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $325.69
| Professional | | $230.15 | $230.15 | $325.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $230.15
| Professional | | $230.15 | $230.15 | $230.15 |