- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.35 / $307.35 / $307.35
| Facility | | $307.35 | $307.35 | $307.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.27 / $233.74 / $307.35
| Professional | | $209.27 | $233.74 | $307.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.42 / $284.26 / $291.33
| Professional | | $240.42 | $284.26 | $291.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.13 / $301.11 / $378.62
| Professional | | $298.13 | $301.11 | $378.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $92.42 / $257.14 / $1,140.66
| Facility | | $92.42 | $257.14 | $1,140.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.30 / $213.71 / $341.65
| Professional | | $168.30 | $213.71 | $341.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.53 / $210.76 / $336.60
| Professional | | $105.53 | $210.76 | $336.60 |