- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.72 / $157.72 / $210.12
| Facility | | $157.72 | $157.72 | $210.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.72 / $163.44 / $249.48
| Professional | | $157.72 | $163.44 | $249.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.27 / $316.33 / $1,390.66
| Facility | | $301.27 | $316.33 | $1,390.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.87 / $183.50 / $243.75
| Professional | | $166.87 | $183.50 | $243.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.57 / $218.57 / $218.57
| Facility | | $218.57 | $218.57 | $218.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.56 / $159.56 / $225.13
| Professional | | $159.56 | $159.56 | $225.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.72 / $243.85 / $1,607.39
| Facility | | $157.72 | $243.85 | $1,607.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.53 / $150.31 / $366.20
| Professional | | $124.53 | $150.31 | $366.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.81 / $150.31 / $255.08
| Professional | | $115.81 | $150.31 | $255.08 |