- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.96 / $165.96 / $446.68
| Facility | | $165.96 | $165.96 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $213.80 / $275.42
| Professional | | $162.18 | $213.80 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $354.81 / $426.58
| Facility | | $109.65 | $354.81 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Professional | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $245.47
| Facility | | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $239.88 / $436.52
| Professional | | $125.89 | $239.88 | $436.52 |