- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.70 / $302.70 / $302.70
| Facility | | $302.70 | $302.70 | $302.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.74 / $302.70 / $302.70
| Professional | | $153.74 | $302.70 | $302.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.02 / $268.02 / $268.02
| Professional | | $268.02 | $268.02 | $268.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.66 / $231.66 / $358.10
| Facility | | $231.66 | $231.66 | $358.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.11 / $231.66 / $342.75
| Professional | | $169.11 | $231.66 | $342.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.40 / $179.65 / $247.32
| Professional | | $106.40 | $179.65 | $247.32 |