- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.48 / $122.48 / $122.48
| Facility | | $122.48 | $122.48 | $122.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.45 / $122.48 / $152.37
| Professional | | $86.45 | $122.48 | $152.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.00 / $176.27 / $245.45
| Facility | | $151.00 | $176.27 | $245.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.02 / $167.46 / $176.27
| Professional | | $141.02 | $167.46 | $176.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.15 / $544.16 / $1,511.40
| Facility | | $110.15 | $544.16 | $1,511.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.38 / $216.64 / $259.56
| Professional | | $204.38 | $216.64 | $259.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.07 / $522.11 / $1,190.08
| Facility | | $323.07 | $522.11 | $1,190.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.38 / $204.38 / $210.40
| Professional | | $204.38 | $204.38 | $210.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.47 / $176.27 / $923.64
| Facility | | $58.47 | $176.27 | $923.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.62 / $90.19 / $204.01
| Professional | | $58.62 | $90.19 | $204.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.11 / $105.86 / $309.62
| Professional | | $67.11 | $105.86 | $309.62 |