- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.39 / $208.39 / $208.39
| Facility | | $208.39 | $208.39 | $208.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.08 / $159.94 / $208.39
| Professional | | $159.08 | $159.94 | $208.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.86 / $274.86 / $274.86
| Professional | | $274.86 | $274.86 | $274.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.80 / $159.94 / $214.33
| Facility | | $117.80 | $159.94 | $214.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.33 / $1,009.33 / $1,009.33
| Professional | | $1,009.33 | $1,009.33 | $1,009.33 |