- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.08 / $204.24 / $210.79
| Facility | | $138.08 | $204.24 | $210.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.08 / $160.88 / $287.66
| Professional | | $138.08 | $160.88 | $287.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.22 / $317.33 / $1,395.05
| Facility | | $302.22 | $317.33 | $1,395.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.06 / $175.88 / $244.51
| Professional | | $160.06 | $175.88 | $244.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.52 / $166.52 / $166.52
| Facility | | $166.52 | $166.52 | $166.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.56 / $121.56 / $177.52
| Professional | | $121.56 | $121.56 | $177.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.08 / $243.58 / $1,389.02
| Facility | | $138.08 | $243.58 | $1,389.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.80 / $162.16 / $284.26
| Professional | | $110.80 | $162.16 | $284.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.80 / $150.78 / $204.88
| Professional | | $110.80 | $150.78 | $204.88 |