- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.82 / $147.82 / $258.69
| Facility | | $147.82 | $147.82 | $258.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.82 / $181.20 / $250.34
| Professional | | $147.82 | $181.20 | $250.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.38 / $216.38 / $216.38
| Professional | | $216.38 | $216.38 | $216.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $505.72 / $1,392.99 / $1,443.76
| Facility | | $505.72 | $1,392.99 | $1,443.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.44 / $1,351.44 / $2,226.23
| Professional | | $1,351.44 | $1,351.44 | $2,226.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.84 / $254.57 / $254.57
| Professional | | $241.84 | $254.57 | $254.57 |