- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $364.28 / $364.28 / $364.28
| Facility | | $364.28 | $364.28 | $364.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.23 / $300.23 / $364.28
| Professional | | $300.23 | $300.23 | $364.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.52 / $557.63 / $567.27
| Professional | | $476.52 | $557.63 | $567.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.50 / $586.30 / $737.24
| Professional | | $580.50 | $586.30 | $737.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.69 / $364.28 / $2,352.03
| Facility | | $243.69 | $364.28 | $2,352.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.47 / $247.71 / $398.94
| Professional | | $199.47 | $247.71 | $398.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.55 / $247.71 / $505.11
| Professional | | $141.55 | $247.71 | $505.11 |