- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.16 / $152.16 / $152.16
| Facility | | $152.16 | $152.16 | $152.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.99 / $152.16 / $152.16
| Professional | | $97.99 | $152.16 | $152.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $403.28 / $803.48 / $1,463.40
| Facility | | $403.28 | $803.48 | $1,463.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.12 / $266.44 / $359.69
| Professional | | $253.12 | $266.44 | $359.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.88 / $138.76 / $173.19
| Facility | | $129.88 | $138.76 | $173.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.15 / $213.15 / $213.15
| Professional | | $213.15 | $213.15 | $213.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.35 / $172.35 / $172.35
| Facility | | $172.35 | $172.35 | $172.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.35 / $172.35 / $309.00
| Professional | | $172.35 | $172.35 | $309.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.16 / $192.54 / $192.54
| Facility | | $152.16 | $192.54 | $192.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.02 / $192.54 / $279.76
| Professional | | $142.02 | $192.54 | $279.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.67 / $197.17 / $226.74
| Professional | | $161.67 | $197.17 | $226.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.65 / $131.74 / $150.19
| Facility | | $1.65 | $131.74 | $150.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.08 / $127.37 / $178.02
| Professional | | $83.08 | $127.37 | $178.02 |