- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.70 / $192.70 / $4,129.42
| Facility | | $192.70 | $192.70 | $4,129.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.53 / $142.54 / $207.65
| Professional | | $142.53 | $142.54 | $207.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.65 / $292.81 / $300.08
| Professional | | $247.65 | $292.81 | $300.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.25 / $290.12 / $364.81
| Professional | | $287.25 | $290.12 | $364.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.63 / $207.65 / $1,140.98
| Facility | | $115.63 | $207.65 | $1,140.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.07 / $177.60 / $214.21
| Professional | | $103.07 | $177.60 | $214.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.93 / $177.60 / $264.86
| Professional | | $78.93 | $177.60 | $264.86 |