- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.31 / $162.31 / $162.31
| Facility | | $162.31 | $162.31 | $162.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.75 / $107.41 / $124.66
| Professional | | $92.75 | $107.41 | $124.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.66 / $138.66 / $138.66
| Facility | | $138.66 | $138.66 | $138.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.45 / $104.45 / $104.45
| Professional | | $104.45 | $104.45 | $104.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.83 / $593.79 / $593.79
| Facility | | $202.83 | $593.79 | $593.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.32 / $741.56 / $955.65
| Professional | | $729.32 | $741.56 | $955.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.83 / $137.49 / $234.56
| Professional | | $105.83 | $137.49 | $234.56 |