- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.08 / $235.46 / $3,156.59
| Facility | | $160.08 | $235.46 | $3,156.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.44 / $178.21 / $588.05
| Professional | | $176.44 | $178.21 | $588.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.41 / $220.53 / $288.55
| Professional | | $155.41 | $220.53 | $288.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.52 / $250.32 / $284.27
| Facility | | $189.52 | $250.32 | $284.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.52 / $189.52 / $193.31
| Professional | | $189.52 | $189.52 | $193.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $708.92 / $708.92 / $708.92
| Facility | | $708.92 | $708.92 | $708.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.46 / $166.46 / $176.45
| Facility | | $166.46 | $166.46 | $176.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $176.45
| Professional | | $176.45 | $176.45 | $176.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.33 / $176.45 / $220.21
| Professional | | $162.33 | $176.45 | $220.21 |