- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.08 / $257.08 / $257.08
| Facility | | $257.08 | $257.08 | $257.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.57 / $257.08 / $257.08
| Professional | | $130.57 | $257.08 | $257.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.62 / $227.62 / $227.62
| Professional | | $227.62 | $227.62 | $227.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.02 / $197.02 / $310.70
| Facility | | $197.02 | $197.02 | $310.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.82 / $197.02 / $272.06
| Professional | | $143.82 | $197.02 | $272.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.63 / $136.63 / $136.63
| Facility | | $136.63 | $136.63 | $136.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.71 / $152.57 / $235.11
| Professional | | $101.71 | $152.57 | $235.11 |