- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.63 / $131.63 / $131.63
| Facility | | $131.63 | $131.63 | $131.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.12 / $131.63 / $144.44
| Professional | | $131.12 | $131.63 | $144.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.61 / $171.56 / $1,433.21
| Facility | | $168.61 | $171.56 | $1,433.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.14 / $160.38 / $207.69
| Professional | | $91.14 | $160.38 | $207.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.19 / $150.07 / $208.30
| Facility | | $130.19 | $150.07 | $208.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.92 / $141.51 / $975.32
| Professional | | $103.92 | $141.51 | $975.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.80 / $131.87 / $240.48
| Professional | | $106.80 | $131.87 | $240.48 |