- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.93 / $285.93 / $285.93
| Facility | | $285.93 | $285.93 | $285.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.27 / $219.47 / $285.93
| Professional | | $218.27 | $219.47 | $285.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.39 / $302.39 / $302.39
| Professional | | $302.39 | $302.39 | $302.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.90 / $219.47 / $294.08
| Facility | | $128.90 | $219.47 | $294.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.36 / $1,328.36 / $1,328.36
| Professional | | $1,328.36 | $1,328.36 | $1,328.36 |