- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.75 / $173.08 / $1,436.60
| Facility | | $140.75 | $173.08 | $1,436.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.75 / $140.75 / $173.12
| Professional | | $140.75 | $140.75 | $173.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.39 / $188.20 / $198.11
| Facility | | $168.39 | $188.20 | $198.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.48 / $166.48 / $166.48
| Professional | | $166.48 | $166.48 | $166.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.82 / $161.82 / $161.82
| Facility | | $161.82 | $161.82 | $161.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $161.82 / $161.82
| Professional | | $100.00 | $161.82 | $161.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.50 / $160.13 / $173.12
| Facility | | $108.50 | $160.13 | $173.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.30 / $170.49 / $173.38
| Professional | | $154.30 | $170.49 | $173.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.30 / $170.49 / $173.38
| Professional | | $154.30 | $170.49 | $173.38 |