- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.09 / $236.09 / $1,101.04
| Facility | | $236.09 | $236.09 | $1,101.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.43 / $236.09 / $1,293.63
| Professional | | $166.43 | $236.09 | $1,293.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.16 / $267.77 / $431.28
| Professional | | $200.16 | $267.77 | $431.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $66.69 / $133.49
| Professional | | $32.34 | $66.69 | $133.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.17 / $349.83 / $445.97
| Professional | | $212.17 | $349.83 | $445.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.96 / $225.92 / $364.42
| Professional | | $170.96 | $225.92 | $364.42 |