- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $263.03 / $263.03
| Facility | | $245.47 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $120.23
| Professional | | $104.71 | $104.71 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $123.03 / $331.13
| Facility | | $102.33 | $123.03 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $109.65
| Professional | | $104.71 | $104.71 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $147.91
| Facility | | $104.71 | $104.71 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $107.15
| Professional | | $104.71 | $104.71 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $263.03
| Facility | | $245.47 | $245.47 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $107.15 / $158.49
| Professional | | $104.71 | $107.15 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $104.71 / $125.89
| Professional | | $97.72 | $104.71 | $125.89 |