- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.54 / $208.54 / $208.54
| Facility | | $208.54 | $208.54 | $208.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.83 / $173.09 / $208.54
| Professional | | $166.83 | $173.09 | $208.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.97 / $1.00 / $227.83
| Facility | | $0.97 | $1.00 | $227.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.01 / $347.56 / $540.20
| Professional | | $186.01 | $347.56 | $540.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Facility | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Professional | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.83 / $208.54 / $375.37
| Facility | | $166.83 | $208.54 | $375.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.45 / $792.45 / $792.45
| Professional | | $792.45 | $792.45 | $792.45 |