- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $244.51 / $244.51 / $244.51
| Facility | | $244.51 | $244.51 | $244.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.51 / $244.51 / $244.51
| Professional | | $244.51 | $244.51 | $244.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.08 / $256.08 / $313.58
| Professional | | $256.08 | $256.08 | $313.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.82 / $214.82 / $214.82
| Professional | | $214.82 | $214.82 | $214.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.17 / $298.17 / $910.61
| Professional | | $298.17 | $298.17 | $910.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.57 / $228.86 / $324.22
| Professional | | $152.57 | $228.86 | $324.22 |