- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.12 / $145.12 / $867.85
| Facility | | $145.12 | $145.12 | $867.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.12 / $145.12 / $145.12
| Professional | | $145.12 | $145.12 | $145.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.74 / $971.51 / $1,084.82
| Professional | | $725.74 | $971.51 | $1,084.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.25 / $554.25 / $813.66
| Professional | | $554.25 | $554.25 | $813.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.12 / $289.27 / $723.21
| Facility | | $145.12 | $289.27 | $723.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.73 / $259.14 / $578.57
| Professional | | $105.73 | $259.14 | $578.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.73 / $211.46 / $414.62
| Professional | | $105.73 | $211.46 | $414.62 |