- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.55 / $105.55 / $121.78
| Facility | | $105.55 | $105.55 | $121.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.87 / $105.55 / $123.63
| Professional | | $94.87 | $105.55 | $123.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.07 / $309.07 / $309.07
| Facility | | $309.07 | $309.07 | $309.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.74 / $139.22 / $309.07
| Professional | | $135.74 | $139.22 | $309.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.84 / $144.84 / $227.53
| Facility | | $144.84 | $144.84 | $227.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.73 / $105.73 / $257.77
| Professional | | $105.73 | $105.73 | $257.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.87 / $247.26 / $445.06
| Professional | | $171.87 | $247.26 | $445.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.55 / $115.64 / $192.74
| Professional | | $90.55 | $115.64 | $192.74 |