- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.26 / $120.26 / $547.20
| Facility | | $120.26 | $120.26 | $547.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $120.26 / $183.26
| Professional | | $114.54 | $120.26 | $183.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $249.27 / $461.06 / $806.60
| Facility | | $249.27 | $461.06 | $806.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.12 / $406.33 / $626.39
| Professional | | $119.12 | $406.33 | $626.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.05 / $114.54 / $114.54
| Facility | | $108.05 | $114.54 | $114.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $114.54 / $114.54
| Professional | | $114.54 | $114.54 | $114.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.26 / $162.35 / $573.60
| Facility | | $120.26 | $162.35 | $573.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.56 / $258.56 / $258.56
| Professional | | $258.56 | $258.56 | $258.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $114.54 / $114.54
| Professional | | $114.54 | $114.54 | $114.54 |