- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.20 / $292.20 / $292.20
| Facility | | $292.20 | $292.20 | $292.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.03 / $191.44 / $292.20
| Professional | | $102.03 | $191.44 | $292.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.08 / $276.93 / $294.58
| Facility | | $263.08 | $276.93 | $294.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.77 / $290.77 / $290.77
| Professional | | $290.77 | $290.77 | $290.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.94 / $197.94 / $197.94
| Facility | | $197.94 | $197.94 | $197.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.50 / $197.94 / $513.75
| Professional | | $144.50 | $197.94 | $513.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.03 / $284.39 / $1,651.29
| Facility | | $102.03 | $284.39 | $1,651.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.36 / $176.04 / $450.82
| Professional | | $105.36 | $176.04 | $450.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.36 / $175.46 / $235.78
| Professional | | $105.36 | $175.46 | $235.78 |