- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.63 / $142.63 / $303.08
| Facility | | $142.63 | $142.63 | $303.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.53 / $115.53 / $115.53
| Professional | | $115.53 | $115.53 | $115.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.02 / $173.25 / $493.07
| Facility | | $138.02 | $173.25 | $493.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.05 / $57.05 / $92.70
| Professional | | $57.05 | $57.05 | $92.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $304.23 / $304.23 / $304.23
| Facility | | $304.23 | $304.23 | $304.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.63 / $142.63 / $144.06
| Professional | | $142.63 | $142.63 | $144.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.63 / $142.63 / $231.06
| Facility | | $142.63 | $142.63 | $231.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.53 / $115.53 / $142.63
| Professional | | $115.53 | $115.53 | $142.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.73 / $85.58 / $249.60
| Professional | | $72.73 | $85.58 | $249.60 |