- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.89 / $315.89 / $315.89
| Facility | | $315.89 | $315.89 | $315.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.42 / $298.42 / $315.89
| Professional | | $298.42 | $298.42 | $315.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.99 / $480.02 / $491.96
| Professional | | $405.99 | $480.02 | $491.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.00 / $502.98 / $632.46
| Professional | | $498.00 | $502.98 | $632.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.39 / $315.89 / $2,000.04
| Facility | | $200.39 | $315.89 | $2,000.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.98 / $212.51 / $345.96
| Professional | | $172.98 | $212.51 | $345.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.88 / $191.41 / $345.96
| Professional | | $149.88 | $191.41 | $345.96 |