- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.32 / $186.32 / $186.32
| Facility | | $186.32 | $186.32 | $186.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.32 / $195.61 / $212.94
| Professional | | $186.32 | $195.61 | $212.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.73 / $380.25 / $380.25
| Professional | | $258.73 | $380.25 | $380.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.51 / $203.51 / $203.51
| Facility | | $203.51 | $203.51 | $203.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.56 / $203.51 / $203.51
| Professional | | $148.56 | $203.51 | $203.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.90 / $260.81 / $1,717.84
| Facility | | $104.90 | $260.81 | $1,717.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.32 / $214.70 / $424.07
| Professional | | $108.32 | $214.70 | $424.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.32 / $206.98 / $244.81
| Professional | | $108.32 | $206.98 | $244.81 |