- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.85 / $212.85 / $212.85
| Facility | | $212.85 | $212.85 | $212.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.83 / $163.36 / $212.85
| Professional | | $136.83 | $163.36 | $212.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.08 / $294.08 / $294.08
| Professional | | $294.08 | $294.08 | $294.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.11 / $180.35 / $316.62
| Facility | | $136.11 | $180.35 | $316.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.42 / $1,053.42 / $1,053.42
| Professional | | $1,053.42 | $1,053.42 | $1,053.42 |