- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.23 / $240.23 / $240.23
| Facility | | $240.23 | $240.23 | $240.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.38 / $243.43 / $300.23
| Professional | | $195.38 | $243.43 | $300.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.78 / $314.83 / $354.20
| Professional | | $239.78 | $314.83 | $354.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.62 / $267.62 / $269.81
| Facility | | $267.62 | $267.62 | $269.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.48 / $267.62 / $330.59
| Professional | | $227.48 | $267.62 | $330.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.16 / $1,807.28 / $1,827.09
| Facility | | $504.16 | $1,807.28 | $1,827.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.09 / $217.10 / $302.77
| Professional | | $134.09 | $217.10 | $302.77 |