- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.09 / $73.37 / $1,196.80
| Facility | | $66.09 | $73.37 | $1,196.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.97 / $294.38 / $343.62
| Professional | | $190.97 | $294.38 | $343.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.32 / $281.32 / $281.32
| Professional | | $281.32 | $281.32 | $281.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.27 / $274.27 / $274.27
| Facility | | $274.27 | $274.27 | $274.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.13 / $233.13 / $274.27
| Professional | | $233.13 | $233.13 | $274.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.65 / $181.11 / $246.84
| Professional | | $102.65 | $181.11 | $246.84 |