- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.94 / $144.94 / $1,182.69
| Facility | | $144.94 | $144.94 | $1,182.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.94 / $144.94 / $150.74
| Professional | | $144.94 | $144.94 | $150.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.60 / $154.60 / $154.60
| Professional | | $154.60 | $154.60 | $154.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.02 / $326.58 / $702.31
| Facility | | $314.02 | $326.58 | $702.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $247.19 / $1,504.61
| Professional | | $109.44 | $247.19 | $1,504.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.24 / $392.82 / $392.82
| Professional | | $222.24 | $392.82 | $392.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.17 / $175.85 / $307.27
| Professional | | $81.17 | $175.85 | $307.27 |