- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $282.32 / $282.32 / $282.32
| Facility | | $282.32 | $282.32 | $282.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.12 / $216.68 / $282.32
| Professional | | $73.12 | $216.68 | $282.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.72 / $174.72 / $174.72
| Professional | | $174.72 | $174.72 | $174.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.55 / $216.68 / $290.35
| Facility | | $70.55 | $216.68 | $290.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.58 / $1,283.58 / $1,283.58
| Professional | | $1,283.58 | $1,283.58 | $1,283.58 |