- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.41 / $175.48 / $253.11
| Facility | | $150.41 | $175.48 | $253.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.91 / $195.02 / $253.11
| Professional | | $148.91 | $195.02 | $253.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.38 / $216.38 / $216.38
| Professional | | $216.38 | $216.38 | $216.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.12 / $267.80 / $563.54
| Professional | | $107.12 | $267.80 | $563.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $399.02 / $479.36
| Professional | | $50.00 | $399.02 | $479.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.57 / $254.57 / $254.57
| Professional | | $254.57 | $254.57 | $254.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.38 / $4.38 / $4.38
| Professional | | $4.38 | $4.38 | $4.38 |