- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Facility | | $436.52 | $436.52 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $204.17 / $309.03
| Professional | | $154.88 | $204.17 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $338.84 / $537.03
| Professional | | $218.78 | $338.84 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $354.81 / $741.31
| Professional | | $181.97 | $354.81 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $363.08 / $588.84
| Professional | | $239.88 | $363.08 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $338.84 / $602.56
| Professional | | $208.93 | $338.84 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Facility | | $162.18 | $162.18 | $162.18 |