- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.23 / $212.23 / $212.23
| Facility | | $212.23 | $212.23 | $212.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.10 / $172.10 / $268.48
| Professional | | $172.10 | $172.10 | $268.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.00 / $302.31 / $331.87
| Professional | | $220.00 | $302.31 | $331.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.39 / $1,104.39 / $1,104.39
| Professional | | $1,104.39 | $1,104.39 | $1,104.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.10 / $102.95 / $123.35
| Professional | | $98.10 | $102.95 | $123.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.10 / $235.66 / $574.14
| Facility | | $172.10 | $235.66 | $574.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.24 / $471.46 / $1,779.80
| Professional | | $373.24 | $471.46 | $1,779.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.24 / $434.96 / $667.90
| Professional | | $373.24 | $434.96 | $667.90 |