- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.14 / $134.30 / $273.12
| Facility | | $100.14 | $134.30 | $273.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.14 / $100.14 / $110.15
| Professional | | $100.14 | $100.14 | $110.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.03 / $43.72 / $58.82
| Facility | | $36.03 | $43.72 | $58.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.20 / $95.20 / $95.20
| Professional | | $95.20 | $95.20 | $95.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.62 / $106.62 / $106.62
| Facility | | $106.62 | $106.62 | $106.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.62 / $106.62 / $107.88
| Professional | | $106.62 | $106.62 | $107.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.20 / $109.16 / $115.46
| Professional | | $95.20 | $109.16 | $115.46 |