- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Facility | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $169.82 / $436.52
| Professional | | $112.20 | $169.82 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $933.25
| Facility | | $758.58 | $758.58 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $190.55
| Professional | | $162.18 | $162.18 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $194.98 / $288.40
| Professional | | $131.83 | $194.98 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $169.82 / $489.78
| Professional | | $131.83 | $169.82 | $489.78 |