- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.71 / $242.71 / $242.71
| Facility | | $242.71 | $242.71 | $242.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.71 / $242.71 / $242.71
| Professional | | $242.71 | $242.71 | $242.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.70 / $93.70 / $93.70
| Professional | | $93.70 | $93.70 | $93.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.04 / $116.04 / $116.04
| Professional | | $116.04 | $116.04 | $116.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.71 / $259.70 / $354.07
| Facility | | $242.71 | $259.70 | $354.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.20 / $290.20 / $290.20
| Professional | | $290.20 | $290.20 | $290.20 |