- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.63 / $271.63 / $271.63
| Facility | | $271.63 | $271.63 | $271.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.63 / $271.63 / $271.63
| Professional | | $271.63 | $271.63 | $271.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.50 / $284.50 / $284.50
| Professional | | $284.50 | $284.50 | $284.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.41 / $200.41 / $200.41
| Professional | | $200.41 | $200.41 | $200.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.24 / $331.24 / $1,011.59
| Professional | | $331.24 | $331.24 | $1,011.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.49 / $254.24 / $360.17
| Professional | | $169.49 | $254.24 | $360.17 |