- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.96 / $173.96 / $1,178.55
| Facility | | $173.96 | $173.96 | $1,178.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.81 / $198.81 / $198.81
| Professional | | $198.81 | $198.81 | $198.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.51 / $260.94 / $342.94
| Professional | | $248.51 | $260.94 | $342.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $451.64 / $612.20 / $1,416.94
| Facility | | $451.64 | $612.20 | $1,416.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.84 / $248.51 / $313.12
| Facility | | $193.84 | $248.51 | $313.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.37 / $141.75 / $248.51
| Professional | | $104.37 | $141.75 | $248.51 |