- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.73 / $108.10 / $231.94
| Facility | | $104.73 | $108.10 | $231.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $105.78 / $126.99
| Professional | | $104.73 | $105.78 | $126.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.02 / $73.13 / $110.55
| Facility | | $44.02 | $73.13 | $110.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.55 / $110.55 / $112.76
| Professional | | $110.55 | $110.55 | $112.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.80 / $98.80 / $104.73
| Facility | | $98.80 | $98.80 | $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
- $104.73 / $104.73 / $124.61
| Professional | | $104.73 | $104.73 | $124.61 |