- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.62 / $186.62 / $275.04
| Facility | | $186.62 | $186.62 | $275.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.71 / $186.62 / $202.65
| Professional | | $179.71 | $186.62 | $202.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.27 / $218.27 / $218.27
| Facility | | $218.27 | $218.27 | $218.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.34 / $218.27 / $218.27
| Professional | | $159.34 | $218.27 | $218.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.67 / $237.03 / $1,743.72
| Facility | | $108.67 | $237.03 | $1,743.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.22 / $188.11 / $390.34
| Professional | | $112.22 | $188.11 | $390.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.22 / $168.32 / $241.49
| Professional | | $112.22 | $168.32 | $241.49 |