- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.15 / $219.15 / $219.15
| Facility | | $219.15 | $219.15 | $219.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.30 / $209.30 / $219.15
| Professional | | $209.30 | $209.30 | $219.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.64 / $333.00 / $341.28
| Professional | | $281.64 | $333.00 | $341.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.13 / $352.62 / $443.39
| Professional | | $349.13 | $352.62 | $443.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.58 / $219.15 / $1,633.27
| Facility | | $163.58 | $219.15 | $1,633.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.01 / $153.08 / $250.46
| Professional | | $120.01 | $153.08 | $250.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.18 / $150.28 / $250.46
| Professional | | $100.18 | $150.28 | $250.46 |