- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.25 / $594.44 / $1,157.75
| Facility | | $130.25 | $594.44 | $1,157.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.25 / $130.25 / $135.44
| Professional | | $130.25 | $130.25 | $135.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.29 / $197.52 / $931.84
| Professional | | $156.29 | $197.52 | $931.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $282.20 / $293.49 / $630.89
| Facility | | $282.20 | $293.49 | $630.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.63 / $221.42 / $1,323.55
| Professional | | $123.63 | $221.42 | $1,323.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.71 / $353.00 / $353.00
| Professional | | $199.71 | $353.00 | $353.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.20 / $148.61 / $422.05
| Professional | | $104.20 | $148.61 | $422.05 |