- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.92 / $163.93 / $292.67
| Facility | | $108.92 | $163.93 | $292.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.92 / $108.92 / $108.92
| Professional | | $108.92 | $108.92 | $108.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.55 / $159.21 / $314.86
| Facility | | $103.55 | $159.21 | $314.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $104.73
| Professional | | $104.73 | $104.73 | $104.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $104.73
| Facility | | $104.73 | $104.73 | $104.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $104.73
| Professional | | $104.73 | $104.73 | $104.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.68 / $113.62 / $131.01
| Professional | | $108.68 | $113.62 | $131.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.26 / $104.73 / $116.25
| Professional | | $94.26 | $104.73 | $116.25 |