- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $478.63
| Facility | | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $151.36 / $1,122.02
| Professional | | $120.23 | $151.36 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $194.98 / $239.88
| Facility | | $123.03 | $194.98 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $275.42 / $489.78
| Facility | | $257.04 | $275.42 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $147.91
| Professional | | $120.23 | $120.23 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Facility | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Professional | | $446.68 | $446.68 | $446.68 |