- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.21 / $212.17 / $355.64
| Facility | | $163.21 | $212.17 | $355.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.21 / $164.25 / $197.48
| Professional | | $163.21 | $164.25 | $197.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.28 / $169.37 / $195.54
| Professional | | $152.28 | $169.37 | $195.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.51 / $164.25 / $164.25
| Facility | | $152.51 | $164.25 | $164.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $164.25
| Professional | | $164.25 | $164.25 | $164.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.56 / $218.48 / $821.25
| Facility | | $202.56 | $218.48 | $821.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,623.57 / $3,623.57 / $3,623.57
| Professional | | $3,623.57 | $3,623.57 | $3,623.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.04 / $164.25 / $182.84
| Professional | | $156.04 | $164.25 | $182.84 |