- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.33 / $220.08 / $337.61
| Facility | | $188.33 | $220.08 | $337.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.07 / $132.58 / $225.48
| Professional | | $106.07 | $132.58 | $225.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.52 / $510.52 / $510.52
| Professional | | $510.52 | $510.52 | $510.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $518.70 / $518.70 / $518.70
| Facility | | $518.70 | $518.70 | $518.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.42 / $510.52 / $510.52
| Professional | | $367.42 | $510.52 | $510.52 |