- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $283.12 / $283.12 / $283.12
| Facility | | $283.12 | $283.12 | $283.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.04 / $185.49 / $283.12
| Professional | | $127.04 | $185.49 | $283.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $254.63 / $277.82 / $294.67
| Facility | | $254.63 | $277.82 | $294.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.75 / $275.75 / $275.75
| Professional | | $275.75 | $275.75 | $275.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.25 / $192.25 / $192.25
| Facility | | $192.25 | $192.25 | $192.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.34 / $192.25 / $497.81
| Professional | | $140.34 | $192.25 | $497.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.04 / $275.54 / $1,603.51
| Facility | | $104.04 | $275.54 | $1,603.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $170.56 / $436.80
| Professional | | $102.33 | $170.56 | $436.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.04 / $170.56 / $238.50
| Professional | | $104.04 | $170.56 | $238.50 |