- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $454.25 / $454.25 / $454.25
| Facility | | $454.25 | $454.25 | $454.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.30 / $58.46 / $64.78
| Professional | | $55.30 | $58.46 | $64.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.31 / $164.60 / $182.89
| Facility | | $154.31 | $164.60 | $182.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.20 / $63.20 / $63.20
| Professional | | $63.20 | $63.20 | $63.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.18 / $47.40 / $113.94
| Professional | | $33.18 | $47.40 | $113.94 |