- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $234.42 / $457.09
| Professional | | $114.82 | $234.42 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $169.82 / $239.88
| Professional | | $100.00 | $169.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $151.36 / $251.19 / $331.13
| Professional | 50 | $151.36 | $251.19 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $707.95
| Facility | | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $295.12 / $562.34
| Professional | | $177.83 | $295.12 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $263.03 / $478.63
| Professional | | $123.03 | $263.03 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $223.87 / $467.74
| Professional | | $120.23 | $223.87 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $234.42 / $436.52
| Professional | | $123.03 | $234.42 | $436.52 |