- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.32 / $135.32 / $135.32
| Facility | | $135.32 | $135.32 | $135.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.43 / $135.32 / $415.34
| Professional | | $126.43 | $135.32 | $415.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.65 / $271.52 / $492.97
| Facility | | $241.65 | $271.52 | $492.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.05 / $117.47 / $139.80
| Professional | | $114.05 | $117.47 | $139.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.55 / $152.55 / $153.72
| Facility | | $152.55 | $152.55 | $153.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.36 / $111.36 / $253.73
| Professional | | $111.36 | $111.36 | $253.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.78 / $135.32 / $304.01
| Facility | | $68.78 | $135.32 | $304.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.78 / $68.78 / $68.78
| Professional | | $68.78 | $68.78 | $68.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.40 / $302.06 / $478.47
| Professional | | $176.40 | $302.06 | $478.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.73 / $106.53 / $160.47
| Professional | | $96.73 | $106.53 | $160.47 |