- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.34 / $115.93 / $183.03
| Professional | | $81.34 | $115.93 | $183.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.68 / $115.68 / $135.66
| Professional | | $115.68 | $115.68 | $135.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.68 / $115.68 / $115.68
| Facility | | $115.68 | $115.68 | $115.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.67 / $115.26 / $137.06
| Professional | | $86.67 | $115.26 | $137.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.59 / $76.62 / $111.12
| Facility | | $64.59 | $76.62 | $111.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.76 / $115.31 / $158.60
| Professional | | $76.76 | $115.31 | $158.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.32 / $143.36 / $162.25
| Professional | | $120.32 | $143.36 | $162.25 |