- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.88 / $594.82 / $1,198.22
| Facility | | $151.88 | $594.82 | $1,198.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.88 / $151.88 / $367.54
| Professional | | $145.88 | $151.88 | $367.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.86 / $171.86 / $551.71
| Professional | | $171.86 | $171.86 | $551.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.19 / $246.93 / $740.44
| Professional | | $146.19 | $246.93 | $740.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.60 / $375.01 / $375.01
| Professional | | $173.60 | $375.01 | $375.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.69 / $232.57 / $531.67
| Professional | | $120.69 | $232.57 | $531.67 |