- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.34 / $163.34 / $163.34
| Facility | | $163.34 | $163.34 | $163.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.29 / $163.34 / $184.14
| Professional | | $157.29 | $163.34 | $184.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.48 / $302.48 / $302.48
| Professional | | $302.48 | $302.48 | $302.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.25 / $192.25 / $192.25
| Facility | | $192.25 | $192.25 | $192.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.34 / $192.25 / $192.25
| Professional | | $140.34 | $192.25 | $192.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.04 / $207.48 / $1,603.51
| Facility | | $104.04 | $207.48 | $1,603.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $165.14 / $349.70
| Professional | | $102.33 | $165.14 | $349.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $155.77 / $231.21
| Professional | | $102.33 | $155.77 | $231.21 |