- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.51 / $242.19 / $689.96
| Facility | | $105.51 | $242.19 | $689.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.98 / $105.81 / $127.48
| Professional | | $101.98 | $105.81 | $127.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.80 / $180.61 / $328.48
| Facility | | $115.80 | $180.61 | $328.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.87 / $106.66 / $114.08
| Professional | | $104.87 | $106.66 | $114.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $108.36
| Facility | | $108.36 | $108.36 | $108.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $108.36
| Professional | | $108.36 | $108.36 | $108.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.24 / $106.24 / $127.48
| Professional | | $106.24 | $106.24 | $127.48 |