- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $191.68 / $191.68 / $330.68
| Facility | | $191.68 | $191.68 | $330.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.12 / $191.68 / $1,016.10
| Professional | | $155.12 | $191.68 | $1,016.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.80 / $400.73 / $472.49
| Professional | | $373.80 | $400.73 | $472.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.01 / $355.79 / $448.23
| Professional | | $228.01 | $355.79 | $448.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $191.68 / $275.57 / $575.04
| Facility | | $191.68 | $275.57 | $575.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.33 / $370.46 / $1,821.00
| Professional | | $196.33 | $370.46 | $1,821.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.33 / $333.41 / $477.51
| Professional | | $196.33 | $333.41 | $477.51 |