- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.34 / $232.68 / $232.68
| Facility | | $188.34 | $232.68 | $232.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.91 / $194.23 / $232.68
| Professional | | $134.91 | $194.23 | $232.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.00 / $164.57 / $234.55
| Professional | | $82.00 | $164.57 | $234.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.77 / $271.02 / $565.03
| Facility | | $164.77 | $271.02 | $565.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.36 / $1,066.36 / $1,066.36
| Professional | | $1,066.36 | $1,066.36 | $1,066.36 |