- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $275.42
| Facility | | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $275.42 / $275.42
| Professional | | $104.71 | $275.42 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $501.19 / $1,230.27
| Facility | | $223.87 | $501.19 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $40.74 / $40.74
| Professional | | $32.36 | $40.74 | $40.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $416.87 / $562.34
| Facility | | $213.80 | $416.87 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $436.52 / $602.56
| Facility | | $426.58 | $436.52 | $602.56 |