- 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 / $301.35 / $412.10
| Professional | | $301.35 | $301.35 | $412.10 |
- 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 / $380.78
| Facility | | $235.05 | $301.35 | $380.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.57 / $150.68 / $274.41
| Professional | | $126.57 | $150.68 | $274.41 |