- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $216.68 / $266.52 / $266.52
| Facility | | $216.68 | $266.52 | $266.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.59 / $216.68 / $266.52
| Professional | | $79.59 | $216.68 | $266.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $91.55 / $245.05
| Professional | | $60.00 | $91.55 | $245.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.39 / $84.39 / $84.39
| Professional | | $84.39 | $84.39 | $84.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.74 / $279.85 / $608.87
| Facility | | $158.74 | $279.85 | $608.87 |
- 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 |