- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.75 / $563.40 / $668.40
| Facility | | $97.75 | $563.40 | $668.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.98 / $105.81 / $108.36
| Professional | | $101.98 | $105.81 | $108.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.36 / $112.61 / $118.99
| Facility | | $108.36 | $112.61 | $118.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.73 / $114.73 / $114.73
| Professional | | $114.73 | $114.73 | $114.73 |
- 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 |