- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.83 / $302.83 / $302.83
| Facility | | $302.83 | $302.83 | $302.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.81 / $302.83 / $302.83
| Professional | | $153.81 | $302.83 | $302.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.83 / $302.83 / $375.67
| Facility | | $302.83 | $302.83 | $375.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.41 / $302.83 / $342.91
| Professional | | $257.41 | $302.83 | $342.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.66 / $255.02 / $261.98
| Facility | | $224.66 | $255.02 | $261.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.34 / $179.73 / $261.98
| Professional | | $113.34 | $179.73 | $261.98 |