- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.38 / $214.37 / $1,303.36
| Facility | | $192.38 | $214.37 | $1,303.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.37 / $214.37 / $239.10
| Professional | | $214.37 | $214.37 | $239.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.00 / $274.83 / $375.83
| Professional | | $270.00 | $274.83 | $375.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $499.48 / $677.05 / $1,567.03
| Facility | | $499.48 | $677.05 | $1,567.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.77 / $212.11 / $324.39
| Professional | | $124.77 | $212.11 | $324.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.37 / $274.83 / $398.50
| Facility | | $214.37 | $274.83 | $398.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.43 / $156.76 / $274.83
| Professional | | $115.43 | $156.76 | $274.83 |