- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $363.08 / $407.38
| Facility | | $128.82 | $363.08 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $131.83 / $162.18
| Professional | | $128.82 | $131.83 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $707.95 / $1,548.82
| Facility | | $436.52 | $707.95 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $138.04
| Professional | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $363.08 / $407.38
| Facility | | $128.82 | $363.08 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $138.04 / $186.21
| Professional | | $128.82 | $138.04 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $138.04
| Professional | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Facility | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $354.81
| Professional | | $331.13 | $331.13 | $354.81 |