- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $223.87
| Facility | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $251.19 / $660.69
| Professional | | $158.49 | $251.19 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $446.68 / $2,344.23
| Facility | | $309.03 | $446.68 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $416.87 / $630.96
| Professional | | $407.38 | $416.87 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $3,548.13
| Facility | | $1,148.15 | $1,621.81 | $3,548.13 |