- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $283.25 / $283.25 / $283.25
| Facility | | $283.25 | $283.25 | $283.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.25 / $283.25 / $283.25
| Professional | | $283.25 | $283.25 | $283.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.29 / $323.29 / $323.29
| Professional | | $323.29 | $323.29 | $323.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.07 / $330.07 / $330.07
| Professional | | $330.07 | $330.07 | $330.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.42 / $345.42 / $1,054.89
| Professional | | $345.42 | $345.42 | $1,054.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.75 / $265.12 / $375.59
| Professional | | $176.75 | $265.12 | $375.59 |