- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.46 / $340.46 / $340.46
| Facility | | $340.46 | $340.46 | $340.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.74 / $282.74 / $340.46
| Professional | | $282.74 | $282.74 | $340.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.67 / $604.63 / $615.09
| Professional | | $516.67 | $604.63 | $615.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.00 / $530.25 / $666.75
| Professional | | $525.00 | $530.25 | $666.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $282.74 / $340.46 / $1,865.59
| Facility | | $282.74 | $340.46 | $1,865.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.25 / $301.89 / $452.83
| Professional | | $160.25 | $301.89 | $452.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.34 / $320.49 / $452.40
| Professional | | $140.34 | $320.49 | $452.40 |