- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.71 / $248.71 / $593.64
| Facility | | $248.71 | $248.71 | $593.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.71 / $248.71 / $303.01
| Professional | | $248.71 | $248.71 | $303.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $404.08 / $404.08 / $404.08
| Facility | | $404.08 | $404.08 | $404.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.37 / $313.37 / $324.56
| Professional | | $313.37 | $313.37 | $324.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.73 / $238.38 / $238.38
| Professional | | $86.73 | $238.38 | $238.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $50.00
| Professional | | $40.00 | $40.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.62 / $197.62 / $197.62
| Professional | | $197.62 | $197.62 | $197.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |