- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.35 / $301.35 / $640.37
| Facility | | $301.35 | $301.35 | $640.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.09 / $244.09 / $244.09
| Professional | | $244.09 | $244.09 | $244.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,669.96 / $1,927.86 / $2,247.11
| Facility | | $1,669.96 | $1,927.86 | $2,247.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.54 / $120.54 / $256.14
| Professional | | $120.54 | $120.54 | $256.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.35 / $301.35 / $304.36
| Professional | | $301.35 | $301.35 | $304.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.35 / $301.35 / $488.19
| Facility | | $301.35 | $301.35 | $488.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.09 / $244.09 / $301.35
| Professional | | $244.09 | $244.09 | $301.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.69 / $180.81 / $527.36
| Professional | | $153.69 | $180.81 | $527.36 |