- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.80 / $501.80 / $501.80
| Facility | | $501.80 | $501.80 | $501.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.97 / $156.63 / $197.61
| Professional | | $135.97 | $156.63 | $197.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.91 / $228.25 / $342.21
| Professional | | $177.91 | $228.25 | $342.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.27 / $218.18 / $224.20
| Professional | | $197.27 | $218.18 | $224.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.67 / $571.72 / $724.64
| Professional | | $203.67 | $571.72 | $724.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.74 / $240.31 / $463.19
| Professional | | $191.74 | $240.31 | $463.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.61 / $165.13 / $242.74
| Professional | | $137.61 | $165.13 | $242.74 |