- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.40 / $175.40 / $438.50
| Facility | | $175.40 | $175.40 | $438.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.07 / $142.07 / $175.40
| Professional | | $142.07 | $142.07 | $175.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.73 / $257.83 / $1,254.95
| Facility | | $169.73 | $257.83 | $1,254.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.16 / $70.16 / $166.63
| Professional | | $70.16 | $70.16 | $166.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $374.12 / $374.12 / $374.12
| Facility | | $374.12 | $374.12 | $374.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.10 / $177.42 / $217.41
| Professional | | $111.10 | $177.42 | $217.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.40 / $175.40 / $177.15
| Professional | | $175.40 | $175.40 | $177.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.40 / $175.40 / $438.50
| Facility | | $175.40 | $175.40 | $438.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.07 / $175.40 / $175.40
| Professional | | $142.07 | $175.40 | $175.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.24 / $105.24 / $263.10
| Professional | | $105.24 | $105.24 | $263.10 |