- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.75 / $197.75 / $1,008.35
| Facility | | $197.75 | $197.75 | $1,008.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.75 / $197.75 / $197.75
| Professional | | $197.75 | $197.75 | $197.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $578.08 / $697.77 / $750.57
| Facility | | $578.08 | $697.77 | $750.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.48 / $170.48 / $170.48
| Professional | | $170.48 | $170.48 | $170.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $747.76 / $1,011.43 / $1,452.06
| Facility | | $747.76 | $1,011.43 | $1,452.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.96 / $170.48 / $170.48
| Professional | | $161.96 | $170.48 | $170.48 |