- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.25 / $173.25 / $173.25
| Facility | | $173.25 | $173.25 | $173.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.25 / $182.36 / $182.36
| Professional | | $173.25 | $182.36 | $182.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.54 / $404.21 / $496.55
| Facility | | $206.54 | $404.21 | $496.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.64 / $220.15 / $848.13
| Professional | | $202.64 | $220.15 | $848.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.66 / $198.49 / $382.81
| Professional | | $133.66 | $198.49 | $382.81 |