- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.51 / $184.51 / $212.89
| Facility | | $184.51 | $184.51 | $212.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.85 / $184.51 / $216.12
| Professional | | $165.85 | $184.51 | $216.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.29 / $540.29 / $540.29
| Facility | | $540.29 | $540.29 | $540.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.29 / $246.42 / $540.29
| Professional | | $237.29 | $246.42 | $540.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.20 / $253.20 / $397.75
| Facility | | $253.20 | $253.20 | $397.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.84 / $253.20 / $357.07
| Professional | | $184.84 | $253.20 | $357.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.45 / $432.23 / $702.38
| Professional | | $300.45 | $432.23 | $702.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.29 / $202.16 / $336.93
| Professional | | $158.29 | $202.16 | $336.93 |