- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.81 / $170.03 / $325.41
| Facility | | $112.81 | $170.03 | $325.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $109.55 / $148.96
| Professional | | $108.47 | $109.55 | $148.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.69 / $183.68 / $1,420.32
| Facility | | $111.69 | $183.68 | $1,420.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $108.47
| Professional | | $108.47 | $108.47 | $108.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $108.47
| Facility | | $108.47 | $108.47 | $108.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $108.47
| Professional | | $108.47 | $108.47 | $108.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.56 / $115.12 / $151.86
| Professional | | $112.56 | $115.12 | $151.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.05 / $108.47 / $120.75
| Professional | | $103.05 | $108.47 | $120.75 |