- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.26 / $310.26 / $310.26
| Professional | | $158.26 | $310.26 | $310.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.22 / $188.22 / $251.91
| Facility | | $188.22 | $188.22 | $251.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.40 / $188.22 / $193.87
| Professional | | $137.40 | $188.22 | $193.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.02 / $263.76 / $354.32
| Facility | | $97.02 | $263.76 | $354.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.89 / $336.60 / $354.32
| Professional | | $318.89 | $336.60 | $354.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $264.70 / $318.89
| Professional | | $30.00 | $264.70 | $318.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.26 / $346.02 / $519.03
| Facility | | $310.26 | $346.02 | $519.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.02 / $248.02 / $372.04
| Professional | | $248.02 | $248.02 | $372.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.62 / $204.62 / $204.62
| Facility | | $204.62 | $204.62 | $204.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.94 / $150.28 / $236.75
| Professional | | $138.94 | $150.28 | $236.75 |