- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $415.64 / $519.54 / $519.54
| Facility | | $415.64 | $519.54 | $519.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.67 / $519.54 / $519.54
| Professional | | $450.67 | $519.54 | $519.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.25 / $558.12 / $816.90
| Professional | | $294.25 | $558.12 | $816.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.45 / $1,216.40 / $1,882.54
| Facility | | $100.45 | $1,216.40 | $1,882.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.45 / $136.81 / $555.00
| Professional | | $109.45 | $136.81 | $555.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.24 / $247.50 / $942.30
| Professional | | $40.24 | $247.50 | $942.30 |