- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.36 / $182.36 / $182.36
| Facility | | $182.36 | $182.36 | $182.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.09 / $182.36 / $182.36
| Professional | | $167.09 | $182.36 | $182.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.00 / $304.62 / $826.81
| Professional | | $260.00 | $304.62 | $826.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.16 / $2,118.96 / $2,120.61
| Facility | | $1,052.16 | $2,118.96 | $2,120.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.36 / $327.02 / $954.80
| Professional | | $165.36 | $327.02 | $954.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.37 / $440.43 / $440.43
| Professional | | $196.37 | $440.43 | $440.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.49 / $303.82 / $658.83
| Professional | | $198.49 | $303.82 | $658.83 |