- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.38 / $214.37 / $1,303.36
| Facility | | $192.38 | $214.37 | $1,303.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.37 / $214.37 / $219.86
| Professional | | $214.37 | $214.37 | $219.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.83 / $274.83 / $375.83
| Professional | | $274.83 | $274.83 | $375.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $499.48 / $677.05 / $1,567.03
| Facility | | $499.48 | $677.05 | $1,567.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.37 / $274.83 / $329.80
| Facility | | $214.37 | $274.83 | $329.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.54 / $123.26 / $224.48
| Professional | | $103.54 | $123.26 | $224.48 |