- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.72 / $230.72 / $230.72
| Facility | | $230.72 | $230.72 | $230.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.71 / $230.72 / $263.68
| Professional | | $230.71 | $230.72 | $263.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.06 / $457.06 / $457.06
| Professional | | $457.06 | $457.06 | $457.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.38 / $470.85 / $470.85
| Professional | | $320.38 | $470.85 | $470.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.88 / $260.88 / $260.88
| Facility | | $260.88 | $260.88 | $260.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.44 / $260.88 / $260.88
| Professional | | $190.44 | $260.88 | $260.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.88 / $322.95 / $2,277.66
| Facility | | $129.88 | $322.95 | $2,277.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.13 / $265.87 / $525.12
| Professional | | $134.13 | $265.87 | $525.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.13 / $256.30 / $303.07
| Professional | | $134.13 | $256.30 | $303.07 |