- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.91 / $182.91 / $182.91
| Facility | | $182.91 | $182.91 | $182.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.50 / $182.91 / $323.60
| Professional | | $175.50 | $182.91 | $323.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.00 / $271.06 / $391.72
| Professional | | $215.00 | $271.06 | $391.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.59 / $230.92 / $254.96
| Facility | | $164.59 | $230.92 | $254.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.57 / $222.24 / $230.92
| Professional | | $168.57 | $222.24 | $230.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.45 / $265.00 / $580.39
| Facility | | $164.45 | $265.00 | $580.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.00 / $208.00 / $223.00
| Professional | | $208.00 | $208.00 | $223.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.72 / $249.72 / $249.72
| Professional | | $249.72 | $249.72 | $249.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.91 / $182.72 / $248.55
| Professional | | $122.91 | $182.72 | $248.55 |