- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.47 / $308.47 / $308.47
| Facility | | $308.47 | $308.47 | $308.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.32 / $308.47 / $339.31
| Professional | | $297.32 | $308.47 | $339.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.72 / $321.72 / $321.72
| Professional | | $321.72 | $321.72 | $321.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $338.05 / $411.80
| Professional | | $60.00 | $338.05 | $411.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.02 / $22.37 / $24.02
| Facility | | $19.02 | $22.37 | $24.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.70 / $309.70 / $309.70
| Professional | | $309.70 | $309.70 | $309.70 |