- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.31 / $347.31 / $347.31
| Facility | | $347.31 | $347.31 | $347.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.01 / $272.01 / $347.31
| Professional | | $272.01 | $272.01 | $347.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.35 / $527.75 / $540.87
| Professional | | $446.35 | $527.75 | $540.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.75 / $458.29 / $576.26
| Professional | | $453.75 | $458.29 | $576.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.16 / $347.31 / $1,873.73
| Facility | | $166.16 | $347.31 | $1,873.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.50 / $198.30 / $380.36
| Professional | | $155.50 | $198.30 | $380.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.08 / $190.18 / $380.36
| Professional | | $119.08 | $190.18 | $380.36 |