- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.76 / $154.76 / $154.76
| Facility | | $154.76 | $154.76 | $154.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.97 / $154.76 / $168.20
| Professional | | $140.97 | $154.76 | $168.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.91 / $319.08 / $342.95
| Professional | | $287.91 | $319.08 | $342.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.04 / $154.76 / $292.20
| Facility | | $89.04 | $154.76 | $292.20 |
- 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 |