- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $234.42 / $234.42
| Facility | | $151.36 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $245.47 / $295.12
| Professional | | $181.97 | $245.47 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Professional | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,398.83 / $2,398.83
| Professional | | $1,698.24 | $2,398.83 | $2,398.83 |