- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.58 / $365.77 / $365.77
| Facility | | $311.58 | $365.77 | $365.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.30 / $258.83 / $291.58
| Professional | | $244.30 | $258.83 | $291.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,196.11 / $2,196.11 / $2,196.11
| Facility | | $2,196.11 | $2,196.11 | $2,196.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.14 / $308.18 / $394.75
| Professional | | $197.14 | $308.18 | $394.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.20 / $285.95 / $701.81
| Professional | | $172.20 | $285.95 | $701.81 |