- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $244.73 / $244.73 / $1,658.02
| Facility | | $244.73 | $244.73 | $1,658.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.73 / $244.73 / $244.73
| Professional | | $244.73 | $244.73 | $244.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.62 / $367.10 / $482.48
| Professional | | $349.62 | $367.10 | $482.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $272.70 / $349.62 / $423.04
| Facility | | $272.70 | $349.62 | $423.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.66 / $314.66 / $419.54
| Facility | | $314.66 | $314.66 | $419.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.84 / $192.29 / $318.37
| Professional | | $146.84 | $192.29 | $318.37 |