- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.62 / $183.62 / $183.62
| Facility | | $183.62 | $183.62 | $183.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.22 / $138.22 / $183.62
| Professional | | $138.22 | $138.22 | $183.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.98 / $390.98 / $390.98
| Professional | | $390.98 | $390.98 | $390.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.22 / $183.62 / $292.68
| Facility | | $138.22 | $183.62 | $292.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.34 / $1,307.34 / $1,307.34
| Professional | | $1,307.34 | $1,307.34 | $1,307.34 |