- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.14 / $194.24 / $215.46
| Facility | | $106.14 | $194.24 | $215.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.85 / $116.75 / $203.79
| Professional | | $83.85 | $116.75 | $203.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.38 / $140.38 / $140.38
| Facility | | $140.38 | $140.38 | $140.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.38 / $140.38 / $140.38
| Professional | | $140.38 | $140.38 | $140.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.43 / $80.51 / $128.94
| Facility | | $60.43 | $80.51 | $128.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.29 / $48.32 / $152.29
| Professional | | $38.29 | $48.32 | $152.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.92 / $52.62 / $159.21
| Professional | | $43.92 | $52.62 | $159.21 |