- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.61 / $228.61 / $1,865.44
| Facility | | $228.61 | $228.61 | $1,865.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.61 / $228.61 / $237.75
| Professional | | $228.61 | $228.61 | $237.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.85 / $243.85 / $243.85
| Professional | | $243.85 | $243.85 | $243.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $495.33 / $515.14 / $1,108.23
| Facility | | $495.33 | $515.14 | $1,108.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.74 / $963.73 / $2,375.55
| Professional | | $183.74 | $963.73 | $2,375.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.53 / $619.59 / $619.59
| Professional | | $350.53 | $619.59 | $619.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.02 / $182.89 / $484.65
| Professional | | $128.02 | $182.89 | $484.65 |