- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.83 / $133.83 / $535.90
| Facility | | $133.83 | $133.83 | $535.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $133.83 / $173.97
| Professional | | $127.45 | $133.83 | $173.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.57 / $184.19 / $289.91
| Facility | | $107.57 | $184.19 | $289.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.55 / $189.68 / $235.38
| Professional | | $132.55 | $189.68 | $235.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.24 / $127.45 / $127.45
| Facility | | $120.24 | $127.45 | $127.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $127.45
| Professional | | $127.45 | $127.45 | $127.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.83 / $160.60 / $631.86
| Facility | | $133.83 | $160.60 | $631.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.78 / $233.78 / $233.78
| Professional | | $233.78 | $233.78 | $233.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $127.45
| Professional | | $127.45 | $127.45 | $127.45 |