- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.67 / $125.89 / $1,412.54
| Facility | | $44.67 | $125.89 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $125.89 / $125.89
| Professional | | $44.67 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Facility | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $478.63
| Professional | | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $457.09
| Facility | | $457.09 | $457.09 | $457.09 |