- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $270.62 / $270.62 / $270.62
| Facility | | $270.62 | $270.62 | $270.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.84 / $193.84 / $270.62
| Professional | | $193.84 | $193.84 | $270.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.79 / $411.21 / $421.43
| Professional | | $347.79 | $411.21 | $421.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.25 / $326.48 / $410.53
| Professional | | $323.25 | $326.48 | $410.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.10 / $270.62 / $1,530.87
| Facility | | $153.10 | $270.62 | $1,530.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.98 / $154.51 / $296.37
| Professional | | $115.98 | $154.51 | $296.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.87 / $154.51 / $296.37
| Professional | | $78.87 | $154.51 | $296.37 |