- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $245.47
| Facility | | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.43 / $234.43 / $245.47
| Professional | | $234.43 | $234.43 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.47 / $373.00 / $382.27
| Professional | | $315.47 | $373.00 | $382.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.13 / $395.04 / $496.73
| Professional | | $391.13 | $395.04 | $496.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.16 / $245.47 / $1,743.72
| Facility | | $183.16 | $245.47 | $1,743.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.41 / $171.41 / $280.54
| Professional | | $134.41 | $171.41 | $280.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.22 / $186.87 / $400.44
| Professional | | $112.22 | $186.87 | $400.44 |