- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.95 / $235.05 / $1,429.10
| Facility | | $210.95 | $235.05 | $1,429.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.05 / $235.05 / $241.08
| Professional | | $235.05 | $235.05 | $241.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.35 / $316.42 / $415.86
| Professional | | $301.35 | $316.42 | $415.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $547.67 / $742.39 / $1,718.26
| Facility | | $547.67 | $742.39 | $1,718.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.05 / $301.35 / $361.62
| Facility | | $235.05 | $301.35 | $361.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.57 / $171.88 / $274.41
| Professional | | $126.57 | $171.88 | $274.41 |