- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Facility | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $186.21 / $309.03
| Professional | | $144.54 | $186.21 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $354.81 / $416.87
| Professional | | $181.97 | $354.81 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $213.80 / $562.34
| Facility | | $213.80 | $213.80 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $154.88 / $407.38
| Professional | | $154.88 | $154.88 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $234.42
| Professional | | $177.83 | $177.83 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.96 / $257.04 / $562.34
| Facility | | $165.96 | $257.04 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $102.33
| Professional | | $100.00 | $100.00 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $239.88
| Professional | | $30.20 | $30.20 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.25 / $194.98 / $426.58
| Facility | | $0.25 | $194.98 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $173.78 / $223.87
| Professional | | $131.83 | $173.78 | $223.87 |