- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.50 / $144.50 / $144.50
| Facility | | $144.50 | $144.50 | $144.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.50 / $155.13 / $221.71
| Professional | | $144.50 | $155.13 | $221.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.41 / $293.41 / $293.41
| Facility | | $293.41 | $293.41 | $293.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.38 / $216.38 / $1,227.03
| Professional | | $216.38 | $216.38 | $1,227.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $420.04 / $420.04 / $420.04
| Facility | | $420.04 | $420.04 | $420.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.93 / $254.57 / $271.52
| Professional | | $246.93 | $254.57 | $271.52 |