- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $278.14 / $278.14 / $278.14
| Facility | | $278.14 | $278.14 | $278.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.96 / $162.76 / $946.16
| Facility | | $147.96 | $162.76 | $946.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.27 / $217.85 / $1,172.58
| Professional | | $140.27 | $217.85 | $1,172.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.12 / $200.12 / $200.12
| Facility | | $200.12 | $200.12 | $200.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.05 / $211.50 / $275.54
| Professional | | $137.05 | $211.50 | $275.54 |