- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $277.52 / $277.52 / $277.52
| Facility | | $277.52 | $277.52 | $277.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.52 / $319.48 / $319.48
| Professional | | $277.52 | $319.48 | $319.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.63 / $421.67 / $432.16
| Professional | | $356.63 | $421.67 | $432.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $442.13 / $446.55 / $561.50
| Professional | | $442.13 | $446.55 | $561.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.66 / $305.83 / $2,003.74
| Facility | | $212.66 | $305.83 | $2,003.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.96 / $285.44 / $381.43
| Professional | | $151.96 | $285.44 | $381.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.86 / $190.30 / $452.70
| Professional | | $126.86 | $190.30 | $452.70 |