- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.83 / $137.77 / $137.77
| Facility | | $111.83 | $137.77 | $137.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.83 / $134.52 / $137.77
| Professional | | $111.83 | $134.52 | $137.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.76 / $162.08 / $162.08
| Professional | | $137.76 | $162.08 | $162.08 |
- 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
- $162.08 / $162.08 / $162.08
| Professional | | $162.08 | $162.08 | $162.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.08 / $229.35 / $344.03
| Facility | | $162.08 | $229.35 | $344.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.55 / $162.08 / $279.81
| Professional | | $160.55 | $162.08 | $279.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $597.00
| Facility | | $162.08 | $162.08 | $597.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $162.08
| Professional | | $162.08 | $162.08 | $162.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $227.13
| Professional | | $162.08 | $162.08 | $227.13 |