- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.35 / $739.74 / $3,266.71
| Facility | | $175.35 | $739.74 | $3,266.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $175.35 / $2,636.23
| Professional | | $151.16 | $175.35 | $2,636.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.47 / $209.12 / $240.49
| Facility | | $184.47 | $209.12 | $240.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $151.16
| Professional | | $151.16 | $151.16 | $151.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $85.89 / $153.38
| Professional | | $30.00 | $85.89 | $153.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.65 / $166.28 / $223.63
| Professional | | $149.65 | $166.28 | $223.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $151.16
| Professional | | $151.16 | $151.16 | $151.16 |