- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $158.56
| Facility | | $158.56 | $158.56 | $158.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $205.89
| Professional | | $158.56 | $158.56 | $205.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.81 / $204.40 / $206.46
| Professional | | $185.81 | $204.40 | $206.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.82 / $308.39 / $308.39
| Facility | | $211.82 | $308.39 | $308.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.82 / $307.97 / $583.13
| Professional | | $211.82 | $307.97 | $583.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.69 / $272.14 / $943.35
| Facility | | $142.69 | $272.14 | $943.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.73 / $171.51 / $269.07
| Professional | | $108.73 | $171.51 | $269.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.39 / $309.87 / $476.46
| Facility | | $308.39 | $309.87 | $476.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.87 / $407.25 / $648.61
| Professional | | $309.87 | $407.25 | $648.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.73 / $171.51 / $285.85
| Professional | | $108.73 | $171.51 | $285.85 |