- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.07 / $104.07 / $106.33
| Facility | | $104.07 | $104.07 | $106.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.26 / $106.33 / $123.44
| Professional | | $97.26 | $106.33 | $123.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.36 / $237.72 / $246.77
| Professional | | $183.36 | $237.72 | $246.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.49 / $128.72 / $154.07
| Professional | | $118.49 | $128.72 | $154.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.73 / $106.33 / $209.23
| Facility | | $83.73 | $106.33 | $209.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.77 / $190.92 / $248.31
| Professional | | $91.77 | $190.92 | $248.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.14 / $105.14 / $105.14
| Facility | | $105.14 | $105.14 | $105.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.77 / $183.53 / $232.63
| Professional | | $91.77 | $183.53 | $232.63 |