- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $299.85 / $408.20 / $1,487.90
| Facility | | $299.85 | $408.20 | $1,487.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.73 / $336.63 / $367.74
| Professional | | $169.73 | $336.63 | $367.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.30 / $552.44 / $870.48
| Facility | | $306.30 | $552.44 | $870.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $282.88 / $282.88 / $282.88
| Facility | | $282.88 | $282.88 | $282.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.87 / $227.81 / $2,148.30
| Facility | | $183.87 | $227.81 | $2,148.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.81 / $169.73 / $367.74
| Professional | | $118.81 | $169.73 | $367.74 |