- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.17 / $235.17 / $235.17
| Facility | | $235.17 | $235.17 | $235.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.96 / $223.40 / $225.45
| Professional | | $204.96 | $223.40 | $225.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.67 / $1,266.67 / $1,266.67
| Professional | | $1,076.67 | $1,266.67 | $1,266.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.35 / $193.35 / $193.35
| Facility | | $193.35 | $193.35 | $193.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.96 / $290.02 / $290.02
| Professional | | $204.96 | $290.02 | $290.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.96 / $204.96 / $204.96
| Professional | | $204.96 | $204.96 | $204.96 |