- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.93 / $225.93 / $225.93
| Facility | | $225.93 | $225.93 | $225.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.56 / $225.93 / $225.93
| Professional | | $174.56 | $225.93 | $225.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $384.25 / $806.45 / $12,757.34
| Facility | | $384.25 | $806.45 | $12,757.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.11 / $495.14 / $495.14
| Professional | | $396.11 | $495.14 | $495.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.28 / $381.82 / $463.73
| Facility | | $198.28 | $381.82 | $463.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.36 / $1,328.36 / $1,328.36
| Professional | | $1,328.36 | $1,328.36 | $1,328.36 |