- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.02 / $220.65 / $1,341.55
| Facility | | $198.02 | $220.65 | $1,341.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.65 / $220.65 / $226.30
| Professional | | $220.65 | $220.65 | $226.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.88 / $297.02 / $390.37
| Professional | | $282.88 | $297.02 | $390.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $514.10 / $696.87 / $1,612.91
| Facility | | $514.10 | $696.87 | $1,612.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.65 / $282.88 / $357.45
| Facility | | $220.65 | $282.88 | $357.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.81 / $141.44 / $257.58
| Professional | | $118.81 | $141.44 | $257.58 |