- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.01 / $302.01 / $302.01
| Facility | | $302.01 | $302.01 | $302.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.38 / $302.01 / $302.01
| Professional | | $153.38 | $302.01 | $302.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.38 / $305.38 / $305.38
| Professional | | $305.38 | $305.38 | $305.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.35 / $221.35 / $221.35
| Professional | | $221.35 | $221.35 | $221.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.68 / $271.68 / $403.36
| Facility | | $271.68 | $271.68 | $403.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.33 / $271.68 / $353.20
| Professional | | $198.33 | $271.68 | $353.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.27 / $179.23 / $259.50
| Professional | | $112.27 | $179.23 | $259.50 |