- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.08 / $358.03 / $358.03
| Facility | | $291.08 | $358.03 | $358.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.66 / $291.08 / $358.03
| Professional | | $184.66 | $291.08 | $358.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.94 / $241.69 / $327.68
| Professional | | $157.94 | $241.69 | $327.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.02 / $197.02 / $197.02
| Professional | | $197.02 | $197.02 | $197.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.27 / $369.77 / $817.93
| Facility | | $251.27 | $369.77 | $817.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,750.16 / $1,750.16 / $1,750.16
| Professional | | $1,750.16 | $1,750.16 | $1,750.16 |