- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.43 / $81.28 / $83.18
| Facility | | $79.43 | $81.28 | $83.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $416.87 / $512.86
| Facility | | $158.49 | $416.87 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $524.81 / $1,698.24
| Facility | | $173.78 | $524.81 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $6,025.60
| Professional | | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.96 / $524.81 / $1,905.46
| Facility | | $165.96 | $524.81 | $1,905.46 |