- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $758.58
| Facility | | $316.23 | $316.23 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $316.23 / $478.63
| Professional | | $251.19 | $316.23 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $933.25 / $1,202.26
| Facility | | $263.03 | $933.25 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,174.90
| Professional | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |