- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.15 / $243.15 / $243.15
| Facility | | $243.15 | $243.15 | $243.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.61 / $243.61 / $243.61
| Professional | | $243.61 | $243.61 | $243.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.54 / $280.63 / $280.63
| Professional | | $238.54 | $280.63 | $280.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.82 / $229.82 / $229.82
| Facility | | $229.82 | $229.82 | $229.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.61 / $243.61 / $344.73
| Professional | | $243.61 | $243.61 | $344.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.44 / $243.61 / $243.61
| Professional | | $97.44 | $243.61 | $243.61 |