- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.70 / $314.70 / $314.70
| Facility | | $314.70 | $314.70 | $314.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.66 / $311.62 / $342.47
| Professional | | $204.66 | $311.62 | $342.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.52 / $289.52 / $443.25
| Professional | | $289.52 | $289.52 | $443.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $569.27 / $1,918.67 / $1,988.64
| Facility | | $569.27 | $1,918.67 | $1,988.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.74 / $364.00 / $813.27
| Professional | | $264.74 | $364.00 | $813.27 |