- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.53 / $195.83 / $353.42
| Facility | | $186.53 | $195.83 | $353.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.20 / $195.83 / $576.00
| Professional | | $195.20 | $195.83 | $576.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.48 / $208.48 / $312.72
| Facility | | $208.48 | $208.48 | $312.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.48 / $208.48 / $212.65
| Professional | | $208.48 | $208.48 | $212.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.17 / $215.17 / $215.17
| Facility | | $215.17 | $215.17 | $215.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.17 / $215.17 / $215.17
| Professional | | $215.17 | $215.17 | $215.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.31 / $217.10 / $230.54
| Professional | | $184.31 | $217.10 | $230.54 |