- 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 / $173.78 / $346.74
| Professional | | $144.54 | $173.78 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $660.69 / $1,348.96
| Facility | | $524.81 | $660.69 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $147.91 / $177.83
| Professional | | $141.25 | $147.91 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $263.03 / $346.74
| Facility | | $173.78 | $263.03 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Professional | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $181.97 / $239.88
| Facility | | $100.00 | $181.97 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $144.54
| Professional | | $144.54 | $144.54 | $144.54 |