- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.82 / $162.82 / $162.82
| Facility | | $162.82 | $162.82 | $162.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.82 / $206.20 / $206.20
| Professional | | $162.82 | $206.20 | $206.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.24 / $247.40 / $253.56
| Professional | | $209.24 | $247.40 | $253.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.38 / $288.23 / $362.43
| Professional | | $285.38 | $288.23 | $362.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.98 / $206.20 / $1,197.00
| Facility | | $97.98 | $206.20 | $1,197.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.16 / $167.47 / $186.08
| Professional | | $89.16 | $167.47 | $186.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.43 / $167.47 / $246.18
| Professional | | $74.43 | $167.47 | $246.18 |