- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $177.83 / $177.83
| Facility | | $151.36 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $162.18 / $331.13
| Professional | | $123.03 | $162.18 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $154.88 / $323.59
| Professional | | $97.72 | $154.88 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $165.96 / $416.87
| Professional | | $123.03 | $165.96 | $416.87 |