- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.54 / $176.54 / $2,072.69
| Facility | | $176.54 | $176.54 | $2,072.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.54 / $176.54 / $187.57
| Professional | | $176.54 | $176.54 | $187.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.58 / $222.74 / $290.14
| Facility | | $181.58 | $222.74 | $290.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.57 / $187.57 / $187.57
| Professional | | $187.57 | $187.57 | $187.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.54 / $291.29 / $353.08
| Facility | | $176.54 | $291.29 | $353.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.40 / $790.40 / $790.40
| Professional | | $790.40 | $790.40 | $790.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $201.75 / $232.28 / $316.08
| Facility | | $201.75 | $232.28 | $316.08 |