- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.45 / $303.45 / $303.45
| Facility | | $303.45 | $303.45 | $303.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.74 / $250.74 / $303.45
| Professional | | $250.74 | $250.74 | $303.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.62 / $558.91 / $568.58
| Professional | | $477.62 | $558.91 | $568.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.75 / $488.59 / $614.36
| Professional | | $483.75 | $488.59 | $614.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.06 / $303.45 / $2,207.17
| Facility | | $236.06 | $303.45 | $2,207.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.60 / $247.45 / $371.18
| Professional | | $166.60 | $247.45 | $371.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.72 / $242.76 / $371.18
| Professional | | $138.72 | $242.76 | $371.18 |