- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $201.05 / $217.10 / $666.29
| Facility | | $201.05 | $217.10 | $666.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $108.36
| Professional | | $108.36 | $108.36 | $108.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.48 / $328.48 / $328.48
| Facility | | $328.48 | $328.48 | $328.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.24 / $108.35 / $108.35
| Professional | | $106.24 | $108.35 | $108.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $108.36
| Facility | | $108.36 | $108.36 | $108.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $108.36
| Professional | | $108.36 | $108.36 | $108.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $129.83
| Professional | | $108.36 | $108.36 | $129.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.41 / $249.22 / $972.26
| Facility | | $211.41 | $249.22 | $972.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.81 / $108.36 / $121.68
| Professional | | $105.81 | $108.36 | $121.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.24 / $106.24 / $159.36
| Professional | | $106.24 | $106.24 | $159.36 |