- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $134.90 / $181.97
| Facility | | $104.71 | $134.90 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $239.88
| Professional | | $104.71 | $104.71 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $173.78 / $173.78
| Professional | | $169.82 | $173.78 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $512.86 / $602.56
| Facility | | $169.82 | $512.86 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $489.78
| Professional | | $104.71 | $104.71 | $489.78 |