- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.35 / $238.35 / $238.35
| Facility | | $238.35 | $238.35 | $238.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.68 / $272.25 / $272.25
| Professional | | $234.68 | $272.25 | $272.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.31 / $362.17 / $371.18
| Professional | | $306.31 | $362.17 | $371.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.88 / $380.64 / $478.63
| Professional | | $376.88 | $380.64 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.68 / $238.35 / $1,389.02
| Facility | | $116.68 | $238.35 | $1,389.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.75 / $199.43 / $261.48
| Professional | | $115.75 | $199.43 | $261.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.64 / $199.43 / $261.48
| Professional | | $88.64 | $199.43 | $261.48 |