- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.25 / $227.25 / $227.25
| Facility | | $227.25 | $227.25 | $227.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.83 / $158.21 / $253.14
| Professional | | $85.83 | $158.21 | $253.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.28 / $155.22 / $164.65
| Facility | | $142.28 | $155.22 | $164.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.08 / $154.08 / $154.08
| Professional | | $154.08 | $154.08 | $154.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.52 / $166.52 / $166.52
| Facility | | $166.52 | $166.52 | $166.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.56 / $166.52 / $471.09
| Professional | | $121.56 | $166.52 | $471.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.83 / $243.58 / $1,389.02
| Facility | | $85.83 | $243.58 | $1,389.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.64 / $173.05 / $386.12
| Professional | | $88.64 | $173.05 | $386.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.52 / $150.78 / $204.88
| Professional | | $100.52 | $150.78 | $204.88 |