- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.61 / $204.61 / $204.61
| Facility | | $204.61 | $204.61 | $204.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.61 / $206.65 / $248.39
| Professional | | $204.61 | $206.65 | $248.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.10 / $211.19 / $261.38
| Professional | | $209.10 | $211.19 | $261.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.22 / $346.92 / $1,026.20
| Facility | | $203.22 | $346.92 | $1,026.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.49 / $205.28 / $229.91
| Professional | | $174.49 | $205.28 | $229.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.91 / $246.33 / $308.33
| Facility | | $240.91 | $246.33 | $308.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.44 / $240.91 / $308.33
| Professional | | $215.44 | $240.91 | $308.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.06 / $223.91 / $223.91
| Professional | | $200.06 | $223.91 | $223.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.61 / $204.61 / $225.07
| Professional | | $204.61 | $204.61 | $225.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.28 / $205.28 / $205.28
| Facility | | $205.28 | $205.28 | $205.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.28 / $205.28 / $224.64
| Professional | | $205.28 | $205.28 | $224.64 |