- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.44 / $204.44 / $204.44
| Facility | | $204.44 | $204.44 | $204.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.88 / $204.44 / $226.38
| Professional | | $125.88 | $204.44 | $226.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.08 / $377.08 / $377.08
| Professional | | $377.08 | $377.08 | $377.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.61 / $482.61 / $482.61
| Facility | | $482.61 | $482.61 | $482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.22 / $482.61 / $482.61
| Professional | | $410.22 | $482.61 | $482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.04 / $183.65 / $382.57
| Professional | | $100.04 | $183.65 | $382.57 |