- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.67 / $108.67 / $108.67
| Facility | | $108.67 | $108.67 | $108.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.67 / $115.22 / $973.47
| Professional | | $108.67 | $115.22 | $973.47 |
- 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 / $224.82
| Professional | | $159.34 | $218.27 | $224.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.71 / $246.31 / $320.20
| Professional | | $152.71 | $246.31 | $320.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.44 / $329.49 / $329.49
| Facility | | $295.44 | $329.49 | $329.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.63 / $236.18 / $354.27
| Professional | | $187.63 | $236.18 | $354.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.33 / $168.32 / $215.53
| Professional | | $129.33 | $168.32 | $215.53 |