- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.82 / $293.62 / $2,157.96
| Facility | | $175.82 | $293.62 | $2,157.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.21 / $181.22 / $212.74
| Professional | | $181.21 | $181.22 | $212.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.20 / $106.20 / $106.20
| Professional | | $106.20 | $106.20 | $106.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.22 / $181.22 / $181.22
| Facility | | $181.22 | $181.22 | $181.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.22 / $181.22 / $181.22
| Professional | | $181.22 | $181.22 | $181.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.00 / $906.10 / $906.10
| Facility | | $258.00 | $906.10 | $906.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.42 / $288.42 / $288.42
| Facility | | $288.42 | $288.42 | $288.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.22 / $181.22 / $217.49
| Professional | | $181.22 | $181.22 | $217.49 |