- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.31 / $325.31 / $325.31
| Facility | | $325.31 | $325.31 | $325.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.53 / $189.53 / $234.79
| Professional | | $189.53 | $189.53 | $234.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.87 / $183.87 / $183.87
| Facility | | $183.87 | $183.87 | $183.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.41 / $154.41 / $408.85
| Professional | | $139.41 | $154.41 | $408.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.81 / $169.73 / $622.34
| Professional | | $118.81 | $169.73 | $622.34 |