- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.16 / $162.97 / $501.00
| Facility | | $156.16 | $162.97 | $501.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $162.97
| Professional | | $162.97 | $162.97 | $162.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.32 / $204.34 / $204.34
| Facility | | $192.32 | $204.34 | $204.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.28 / $173.28 / $173.28
| Professional | | $147.28 | $173.28 | $173.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.97 / $179.28 / $260.77
| Facility | | $162.97 | $179.28 | $260.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $179.28 / $259.70
| Professional | | $162.97 | $179.28 | $259.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.20 / $190.27 / $203.81
| Facility | | $180.20 | $190.27 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $203.81 / $506.79
| Professional | | $141.25 | $203.81 | $506.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $192.32 / $218.36
| Professional | | $162.97 | $192.32 | $218.36 |