- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $208.93 / $208.93
| Facility | | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $173.78 / $223.87
| Professional | | $123.03 | $173.78 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $407.38 / $794.33
| Facility | | $173.78 | $407.38 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $741.31 / $741.31
| Professional | | $588.84 | $741.31 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $245.47 / $380.19
| Facility | | $134.90 | $245.47 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Professional | | $1,071.52 | $1,071.52 | $1,071.52 |