- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.55 / $163.55 / $1,334.53
| Facility | | $163.55 | $163.55 | $1,334.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.55 / $163.55 / $163.55
| Professional | | $163.55 | $163.55 | $163.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.25 / $682.53 / $1,493.71
| Professional | | $196.25 | $682.53 | $1,493.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.35 / $368.52 / $792.78
| Facility | | $354.35 | $368.52 | $792.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.69 / $250.69 / $313.36
| Professional | | $250.69 | $250.69 | $313.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $443.25 / $443.25 / $443.25
| Professional | | $443.25 | $443.25 | $443.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.59 / $98.13 / $198.43
| Professional | | $91.59 | $98.13 | $198.43 |