- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $190.55 / $199.53
| Facility | | $190.55 | $190.55 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $199.53 / $245.47
| Professional | | $173.78 | $199.53 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,754.23 / $4,265.80
| Facility | | $1,380.38 | $2,754.23 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,949.84 / $3,467.37
| Facility | | $977.24 | $1,949.84 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $208.93 / $316.23
| Professional | | $165.96 | $208.93 | $316.23 |