- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.43 / $745.60 / $1,006.56
| Facility | | $407.43 | $745.60 | $1,006.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.87 / $321.87 / $321.87
| Professional | | $321.87 | $321.87 | $321.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.52 / $246.52 / $246.52
| Facility | | $246.52 | $246.52 | $246.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.52 / $246.52 / $246.52
| Professional | | $246.52 | $246.52 | $246.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.98 / $264.83 / $278.07
| Facility | | $186.98 | $264.83 | $278.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Professional | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.54 / $147.91 / $420.80
| Professional | | $103.54 | $147.91 | $420.80 |