- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.76 / $177.76 / $177.76
| Facility | | $177.76 | $177.76 | $177.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.76 / $203.16 / $205.81
| Professional | | $177.76 | $203.16 | $205.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.52 / $274.52 / $274.52
| Facility | | $274.52 | $274.52 | $274.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.41 / $274.52 / $274.52
| Professional | | $200.41 | $274.52 | $274.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.44 / $248.85 / $2,227.59
| Facility | | $133.44 | $248.85 | $2,227.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.80 / $273.13 / $419.41
| Professional | | $137.80 | $273.13 | $419.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.80 / $198.07 / $311.36
| Professional | | $137.80 | $198.07 | $311.36 |