- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.79 / $192.79 / $192.79
| Facility | | $192.79 | $192.79 | $192.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.06 / $192.79 / $233.27
| Professional | | $168.06 | $192.79 | $233.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.37 / $190.91 / $192.78
| Professional | | $181.37 | $190.91 | $192.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.31 / $322.95 / $508.71
| Professional | | $183.31 | $322.95 | $508.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.79 / $314.42 / $418.23
| Facility | | $192.79 | $314.42 | $418.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.07 / $401.40 / $1,287.73
| Professional | | $307.07 | $401.40 | $1,287.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.54 / $331.03 / $508.71
| Facility | | $253.54 | $331.03 | $508.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.54 / $331.03 / $508.71
| Professional | | $253.54 | $331.03 | $508.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.60 / $261.60 / $514.60
| Professional | | $239.60 | $261.60 | $514.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.73 / $391.37 / $492.32
| Professional | | $294.73 | $391.37 | $492.32 |