- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.72 / $206.72 / $206.72
| Facility | | $206.72 | $206.72 | $206.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.72 / $224.21 / $343.42
| Professional | | $206.72 | $224.21 | $343.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.14 / $404.21 / $496.55
| Facility | | $253.14 | $404.21 | $496.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.55 / $268.93 / $1,041.46
| Professional | | $205.55 | $268.93 | $1,041.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.93 / $196.30 / $377.55
| Professional | | $140.93 | $196.30 | $377.55 |