- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.16 / $86.16 / $86.16
| Facility | | $86.16 | $86.16 | $86.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.41 / $71.48 / $86.16
| Professional | | $61.41 | $71.48 | $86.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.78 / $182.78 / $182.78
| Facility | | $182.78 | $182.78 | $182.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.63 / $166.46 / $208.08
| Professional | | $131.63 | $166.46 | $208.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.52 / $103.78 / $168.26
| Facility | | $86.52 | $103.78 | $168.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $57.72 / $199.70
| Professional | | $55.00 | $57.72 | $199.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.28 / $184.92 / $200.88
| Facility | | $118.28 | $184.92 | $200.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.99 / $193.90 / $206.79
| Professional | | $109.99 | $193.90 | $206.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.07 / $220.84 / $251.81
| Professional | | $131.07 | $220.84 | $251.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.50 / $57.72 / $105.41
| Professional | | $38.50 | $57.72 | $105.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.66 / $91.66 / $91.66
| Professional | | $91.66 | $91.66 | $91.66 |