- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.33 / $582.49 / $1,080.85
| Facility | | $157.33 | $582.49 | $1,080.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.33 / $157.33 / $157.33
| Professional | | $157.33 | $157.33 | $157.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.41 / $153.68 / $481.68
| Facility | | $149.41 | $153.68 | $481.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.33 / $181.52 / $319.92
| Professional | | $80.33 | $181.52 | $319.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.81 / $201.03 / $707.98
| Facility | | $174.81 | $201.03 | $707.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.91 / $188.53 / $209.48
| Professional | | $171.91 | $188.53 | $209.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.42 / $73.42 / $104.89
| Professional | | $73.42 | $73.42 | $104.89 |