- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $397.21 / $397.21 / $397.21
| Facility | | $397.21 | $397.21 | $397.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.74 / $397.21 / $397.21
| Professional | | $201.74 | $397.21 | $397.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.60 / $319.60 / $319.60
| Professional | | $319.60 | $319.60 | $319.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.27 / $294.27 / $470.02
| Facility | | $294.27 | $294.27 | $470.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.82 / $294.27 / $411.56
| Professional | | $214.82 | $294.27 | $411.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $276.79 / $314.19 / $322.77
| Facility | | $276.79 | $314.19 | $322.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.63 / $235.73 / $324.52
| Professional | | $139.63 | $235.73 | $324.52 |