- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.61 / $128.82 / $1,202.26
| Facility | | $67.61 | $128.82 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $128.82 / $245.47
| Professional | | $75.86 | $128.82 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $169.82 / $169.82
| Facility | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $912.01
| Professional | | $173.78 | $173.78 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $1,258.93
| Facility | | $457.09 | $457.09 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $204.17 / $407.38
| Professional | | $102.33 | $204.17 | $407.38 |