- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $309.03 / $416.87
| Facility | | $302.00 | $309.03 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $47.86 / $588.84
| Professional | | $30.20 | $47.86 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,202.26 / $1,258.93
| Professional | | $1,148.15 | $1,202.26 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $407.38
| Facility | | $309.03 | $309.03 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $363.08 / $602.56
| Professional | | $44.67 | $363.08 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,202.26 / $1,258.93
| Professional | | $1,148.15 | $1,202.26 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $53.70 / $79.43
| Professional | | $41.69 | $53.70 | $79.43 |