- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.86 / $200.86 / $200.86
| Facility | | $200.86 | $200.86 | $200.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.86 / $200.86 / $260.82
| Professional | | $200.86 | $200.86 | $260.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.81 / $304.50 / $307.57
| Professional | | $276.81 | $304.50 | $307.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.21 / $346.46 / $346.46
| Facility | | $196.21 | $346.46 | $346.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.21 / $346.46 / $534.28
| Professional | | $196.21 | $346.46 | $534.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.80 / $344.76 / $1,587.88
| Facility | | $157.80 | $344.76 | $1,587.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.60 / $157.13 / $261.89
| Professional | | $116.60 | $157.13 | $261.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $345.45 / $346.46 / $460.80
| Facility | | $345.45 | $346.46 | $460.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.08 / $409.45 / $713.79
| Professional | | $288.08 | $409.45 | $713.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.60 / $157.13 / $246.52
| Professional | | $116.60 | $157.13 | $246.52 |