- 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 / $347.28
| Facility | | $214.37 | $274.83 | $347.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.43 / $137.41 / $250.26
| Professional | | $115.43 | $137.41 | $250.26 |