- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.31 / $186.31 / $186.31
| Facility | | $186.31 | $186.31 | $186.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.31 / $268.54 / $306.66
| Professional | | $186.31 | $268.54 | $306.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $319.76 / $319.76 / $547.26
| Facility | | $319.76 | $319.76 | $547.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.42 / $233.42 / $583.88
| Professional | | $233.42 | $233.42 | $583.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.96 / $503.48 / $716.91
| Professional | | $499.96 | $503.48 | $716.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.20 / $500.54 / $547.26
| Professional | | $479.20 | $500.54 | $547.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.09 / $273.02 / $547.26
| Professional | | $228.09 | $273.02 | $547.26 |