- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $468.63 / $468.63 / $733.17
| Facility | | $468.63 | $468.63 | $733.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.45 / $429.48 / $468.63
| Professional | | $387.45 | $429.48 | $468.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.97 / $23.50 / $48.01
| Professional | | $16.97 | $23.50 | $48.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,367.11 / $1,367.11 / $1,367.11
| Facility | | $1,367.11 | $1,367.11 | $1,367.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.76 / $88.76 / $88.76
| Professional | | $88.76 | $88.76 | $88.76 |