- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.27 / $231.27 / $231.27
| Facility | | $231.27 | $231.27 | $231.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.27 / $231.27 / $231.27
| Professional | | $231.27 | $231.27 | $231.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.98 / $263.98 / $263.98
| Professional | | $263.98 | $263.98 | $263.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.36 / $209.36 / $209.36
| Professional | | $209.36 | $209.36 | $209.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.04 / $282.04 / $861.32
| Professional | | $282.04 | $282.04 | $861.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.31 / $216.47 / $369.98
| Professional | | $144.31 | $216.47 | $369.98 |