- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.26 / $393.84 / $393.84
| Facility | | $162.26 | $393.84 | $393.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.26 / $162.26 / $168.34
| Professional | | $162.26 | $162.26 | $168.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.22 / $338.04 / $415.71
| Facility | | $172.22 | $338.04 | $415.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.02 / $169.02 / $240.00
| Professional | | $169.02 | $169.02 | $240.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.58 / $239.58 / $324.51
| Facility | | $239.58 | $239.58 | $324.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.58 / $287.50 / $359.38
| Professional | | $239.58 | $287.50 | $359.38 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $202.82 / $202.82 / $253.63
| Professional | | $202.82 | $202.82 | $253.63 |