- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.15 / $243.61 / $243.61
| Facility | | $243.15 | $243.61 | $243.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.61 / $243.61 / $255.31
| Professional | | $243.61 | $243.61 | $255.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.43 / $135.22 / $181.92
| Facility | | $111.43 | $135.22 | $181.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.61 / $243.61 / $243.61
| Facility | | $243.61 | $243.61 | $243.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.23 / $243.61 / $243.61
| Professional | | $240.23 | $243.61 | $243.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.44 / $243.61 / $243.61
| Professional | | $97.44 | $243.61 | $243.61 |