- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $1,150.20
| Facility | | $108.47 | $108.47 | $1,150.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $783.90
| Professional | | $108.47 | $108.47 | $783.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.73 / $258.50 / $659.03
| Facility | | $124.73 | $258.50 | $659.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.48 / $106.00 / $109.28
| Professional | | $85.48 | $106.00 | $109.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.57 / $206.46 / $435.40
| Facility | | $136.57 | $206.46 | $435.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.26 / $162.46 / $194.64
| Professional | | $153.26 | $162.46 | $194.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.32 / $207.84 / $473.84
| Facility | | $131.32 | $207.84 | $473.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.63 / $153.26 / $153.26
| Professional | | $144.63 | $153.26 | $153.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.28 / $109.28 / $532.86
| Facility | | $109.28 | $109.28 | $532.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.28 / $121.65 / $386.82
| Professional | | $109.28 | $121.65 | $386.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $119.32 / $234.22
| Professional | | $108.47 | $119.32 | $234.22 |