- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $144.54 / $316.23
| Facility | | $104.71 | $144.54 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $144.54
| Professional | | $104.71 | $104.71 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $199.53
| Professional | | $109.65 | $109.65 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Facility | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Professional | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $162.18 / $162.18
| Facility | | $39.81 | $162.18 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.72 / $97.72 / $104.71
| Facility | | $97.72 | $97.72 | $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
- $104.71 / $109.65 / $158.49
| Facility | | $104.71 | $109.65 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $104.71 / $151.36
| Professional | | $95.50 | $104.71 | $151.36 |