- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.83 / $195.83 / $250.12
| Facility | | $195.83 | $195.83 | $250.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.46 / $185.07 / $250.12
| Professional | | $136.46 | $185.07 | $250.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.09 / $271.27 / $364.97
| Facility | | $224.09 | $271.27 | $364.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,138.00 / $3,138.00 / $3,138.00
| Facility | | $3,138.00 | $3,138.00 | $3,138.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.51 / $230.38 / $362.91
| Professional | | $110.51 | $230.38 | $362.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.79 / $203.79 / $294.33
| Professional | | $158.79 | $203.79 | $294.33 |