- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.13 / $326.13 / $326.13
| Facility | | $326.13 | $326.13 | $326.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.13 / $379.81 / $379.81
| Professional | | $326.13 | $379.81 | $379.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.11 / $404.21 / $496.55
| Facility | | $67.11 | $404.21 | $496.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.78 / $74.73 / $358.68
| Professional | | $73.78 | $74.73 | $358.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.07 / $288.73 / $577.38
| Professional | | $130.07 | $288.73 | $577.38 |