- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $162.08
| Facility | | $162.08 | $162.08 | $162.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.66 / $134.52 / $162.08
| Professional | | $129.66 | $134.52 | $162.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.95 / $1.00 / $1.00
| Facility | | $0.95 | $1.00 | $1.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.01 / $347.56 / $540.20
| Professional | | $186.01 | $347.56 | $540.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.55 / $494.83 / $695.52
| Facility | | $285.55 | $494.83 | $695.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.16 / $208.54 / $227.79
| Professional | | $181.16 | $208.54 | $227.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $279.47 / $453.48 / $654.30
| Facility | | $279.47 | $453.48 | $654.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.36 / $179.36 / $191.32
| Professional | | $179.36 | $179.36 | $191.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.28 / $162.08 / $163.61
| Facility | | $131.28 | $162.08 | $163.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $293.82
| Professional | | $162.08 | $162.08 | $293.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $293.82
| Professional | | $162.08 | $162.08 | $293.82 |