- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.20 / $150.30 / $296.27
| Facility | | $72.20 | $150.30 | $296.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.30 / $150.30 / $296.27
| Professional | | $150.30 | $150.30 | $296.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.14 / $105.14 / $140.18
| Professional | | $105.14 | $105.14 | $140.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.69 / $128.69 / $128.69
| Facility | | $128.69 | $128.69 | $128.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.69 / $128.69 / $128.69
| Professional | | $128.69 | $128.69 | $128.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.30 / $203.91 / $352.94
| Facility | | $150.30 | $203.91 | $352.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.88 / $156.88 / $156.88
| Professional | | $156.88 | $156.88 | $156.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.31 / $259.31 / $337.10
| Professional | | $259.31 | $259.31 | $337.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.73 / $300.73 / $858.56
| Facility | | $300.73 | $300.73 | $858.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.51 / $1,323.83 / $1,323.83
| Professional | | $1,015.51 | $1,323.83 | $1,323.83 |