- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $295.12
| Facility | | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $177.83 / $398.11
| Professional | | $77.62 | $177.83 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $316.23 / $602.56
| Professional | | $165.96 | $316.23 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $204.17 / $446.68
| Professional | | $109.65 | $204.17 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $3,090.30
| Facility | | $295.12 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $275.42 / $616.60
| Professional | | $141.25 | $275.42 | $616.60 |