- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.26 / $162.26 / $162.26
| Facility | | $162.26 | $162.26 | $162.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.26 / $162.26 / $192.68
| Professional | | $162.26 | $162.26 | $192.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.23 / $296.77 / $540.86
| Facility | | $184.23 | $296.77 | $540.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.13 / $153.13 / $386.29
| Professional | | $153.13 | $153.13 | $386.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $172.40
| Facility | | $172.40 | $172.40 | $172.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $172.40
| Professional | | $172.40 | $172.40 | $172.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.26 / $191.18 / $310.32
| Facility | | $162.26 | $191.18 | $310.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.00 / $512.00 / $512.00
| Professional | | $512.00 | $512.00 | $512.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.18 / $507.18 / $507.18
| Facility | | $507.18 | $507.18 | $507.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.82 / $202.82 / $202.82
| Professional | | $202.82 | $202.82 | $202.82 |