- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.55 / $131.55 / $1,073.45
| Facility | | $131.55 | $131.55 | $1,073.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.55 / $131.55 / $136.81
| Professional | | $131.55 | $131.55 | $136.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.32 / $140.32 / $140.32
| Professional | | $140.32 | $140.32 | $140.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.02 / $296.43 / $638.03
| Facility | | $285.02 | $296.43 | $638.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.25 / $224.17 / $1,367.09
| Professional | | $99.25 | $224.17 | $1,367.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.71 / $356.54 / $356.54
| Professional | | $201.71 | $356.54 | $356.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.67 / $105.24 / $219.25
| Professional | | $73.67 | $105.24 | $219.25 |