- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.35 / $346.55 / $642.79
| Facility | | $301.35 | $346.55 | $642.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.90 / $201.90 / $250.12
| Professional | | $201.90 | $201.90 | $250.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.88 / $195.88 / $195.88
| Facility | | $195.88 | $195.88 | $195.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,068.59 / $1,068.59 / $1,068.59
| Facility | | $1,068.59 | $1,068.59 | $1,068.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.57 / $180.81 / $662.97
| Professional | | $126.57 | $180.81 | $662.97 |