- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $263.03 / $263.03
| Facility | | $263.03 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $245.47 / $436.52
| Professional | | $186.21 | $245.47 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $302.00 / $363.08
| Facility | | $302.00 | $302.00 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $407.38 / $851.14
| Professional | | $331.13 | $407.38 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Facility | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $120.23 / $562.34
| Professional | | $109.65 | $120.23 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $158.49 / $524.81
| Professional | | $151.36 | $158.49 | $524.81 |