- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.77 / $270.57 / $284.10
| Facility | | $104.77 | $270.57 | $284.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $103.75 / $142.40
| Professional | | $101.72 | $103.75 | $142.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.21 / $103.08 / $111.06
| Professional | | $95.21 | $103.08 | $111.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.96 / $95.96 / $101.72
| Facility | | $95.96 | $95.96 | $101.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $129.54
| Professional | | $101.72 | $101.72 | $129.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.73 / $147.83 / $283.20
| Facility | | $102.73 | $147.83 | $283.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.72 / $100.72 / $515.16
| Professional | | $100.72 | $100.72 | $515.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $124.40
| Professional | | $101.72 | $101.72 | $124.40 |