- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.33 / $206.33 / $206.33
| Facility | | $206.33 | $206.33 | $206.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.33 / $234.27 / $234.27
| Professional | | $206.33 | $234.27 | $234.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.17 / $313.52 / $321.32
| Professional | | $265.17 | $313.52 | $321.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.38 / $327.62 / $411.96
| Professional | | $324.38 | $327.62 | $411.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.30 / $234.27 / $1,528.02
| Facility | | $139.30 | $234.27 | $1,528.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.99 / $209.30 / $232.56
| Professional | | $112.99 | $209.30 | $232.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.02 / $209.30 / $314.64
| Professional | | $93.02 | $209.30 | $314.64 |