- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.70 / $104.70 / $152.26
| Facility | | $104.70 | $104.70 | $152.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.54 / $104.70 / $120.30
| Professional | | $91.54 | $104.70 | $120.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.67 / $111.23 / $145.72
| Professional | | $105.67 | $111.23 | $145.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.77 / $174.38 / $350.30
| Professional | | $151.77 | $174.38 | $350.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.24 / $132.10 / $198.93
| Facility | | $101.24 | $132.10 | $198.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.22 / $208.36 / $699.26
| Professional | | $128.22 | $208.36 | $699.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.77 / $193.51 / $271.13
| Facility | | $151.77 | $193.51 | $271.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.81 / $193.51 / $323.30
| Professional | | $148.81 | $193.51 | $323.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.36 / $215.01 / $292.26
| Professional | | $130.36 | $215.01 | $292.26 |