- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $390.06 / $390.06 / $487.58
| Facility | | $390.06 | $390.06 | $487.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.30 / $487.58 / $487.58
| Professional | | $410.30 | $487.58 | $487.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.00 / $117.71 / $158.36
| Facility | | $97.00 | $117.71 | $158.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.50 / $230.77 / $272.31
| Professional | | $180.50 | $230.77 | $272.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.76 / $665.68 / $1,680.75
| Facility | | $39.76 | $665.68 | $1,680.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.55 / $182.55 / $228.18
| Professional | | $182.55 | $182.55 | $228.18 |