- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.87 / $136.04 / $155.76
| Professional | | $105.87 | $136.04 | $155.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.83 / $138.51 / $207.86
| Professional | | $103.83 | $138.51 | $207.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.57 / $110.57 / $110.57
| Facility | | $110.57 | $110.57 | $110.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.45 / $155.76 / $221.69
| Professional | | $110.45 | $155.76 | $221.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.28 / $136.87 / $256.81
| Professional | | $106.28 | $136.87 | $256.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.87 / $136.04 / $155.76
| Professional | | $105.87 | $136.04 | $155.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.84 / $151.16 / $221.41
| Professional | | $103.84 | $151.16 | $221.41 |