- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.28 / $109.28 / $125.67
| Facility | | $109.28 | $109.28 | $125.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.46 / $118.23 / $187.74
| Professional | | $108.46 | $118.23 | $187.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $108.47
| Facility | | $102.33 | $102.33 | $108.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $108.47
| Professional | | $108.47 | $108.47 | $108.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.28 / $142.37 / $594.63
| Facility | | $109.28 | $142.37 | $594.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $119.32 / $135.59
| Professional | | $108.47 | $119.32 | $135.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.40 / $122.44 / $293.30
| Professional | | $65.40 | $122.44 | $293.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.22 / $204.35 / $498.75
| Facility | | $136.22 | $204.35 | $498.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.16 / $130.16 / $135.59
| Professional | | $130.16 | $130.16 | $135.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $114.98
| Professional | | $108.47 | $108.47 | $114.98 |