- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.26 / $169.85 / $279.72
| Facility | | $104.26 | $169.85 | $279.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.36 / $634.40 / $1,559.20
| Professional | | $360.36 | $634.40 | $1,559.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.10 / $241.75 / $339.34
| Facility | | $125.10 | $241.75 | $339.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.00 / $277.45 / $567.76
| Facility | | $235.00 | $277.45 | $567.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.00 / $960.00 / $960.00
| Professional | | $960.00 | $960.00 | $960.00 |