- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.16 / $156.16 / $162.97
| Facility | | $156.16 | $156.16 | $162.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $196.09
| Professional | | $162.97 | $162.97 | $196.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.61 / $293.36 / $521.54
| Facility | | $208.61 | $293.36 | $521.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.36 / $218.36 / $218.36
| Professional | | $218.36 | $218.36 | $218.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.75 / $153.75 / $207.75
| Facility | | $153.75 | $153.75 | $207.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Professional | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.01 / $167.88 / $233.06
| Facility | | $155.01 | $167.88 | $233.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.24 / $179.27 / $267.29
| Professional | | $122.24 | $179.27 | $267.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $195.58 / $218.36
| Professional | | $162.97 | $195.58 | $218.36 |