- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $357.52 / $357.52 / $357.52
| Facility | | $357.52 | $357.52 | $357.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.47 / $310.47 / $357.52
| Professional | | $310.47 | $310.47 | $357.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.47 / $543.25 / $556.77
| Professional | | $459.47 | $543.25 | $556.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $429.75 / $434.05 / $545.78
| Professional | | $429.75 | $434.05 | $545.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.62 / $357.52 / $1,982.96
| Facility | | $180.62 | $357.52 | $1,982.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.11 / $277.39 / $391.54
| Professional | | $154.11 | $277.39 | $391.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.28 / $277.39 / $391.54
| Professional | | $123.28 | $277.39 | $391.54 |