- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.40 / $371.40 / $371.40
| Facility | | $371.40 | $371.40 | $371.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.14 / $268.06 / $268.06
| Professional | | $255.14 | $268.06 | $268.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.92 / $209.92 / $209.92
| Facility | | $209.92 | $209.92 | $209.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.87 / $370.87 / $463.59
| Professional | | $370.87 | $370.87 | $463.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.60 / $150.72 / $358.85
| Professional | | $125.60 | $150.72 | $358.85 |