- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $245.47 / $331.13
| Professional | | $112.20 | $245.47 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $245.47 / $281.84
| Professional | | $218.78 | $245.47 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $309.03 / $602.56
| Professional | | $85.11 | $309.03 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.26 / $66.07 / $66.07
| Facility | | $60.26 | $66.07 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $269.15 / $269.15
| Professional | | $269.15 | $269.15 | $269.15 |