- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.81 / $134.10 / $140.41
| Facility | | $97.81 | $134.10 | $140.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.72 / $112.00 / $140.41
| Professional | | $79.72 | $112.00 | $140.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.38 / $153.38 / $153.38
| Facility | | $153.38 | $153.38 | $153.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.38 / $153.38 / $153.38
| Professional | | $153.38 | $153.38 | $153.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.30 / $120.30 / $145.07
| Facility | | $120.30 | $120.30 | $145.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.26 / $120.30 / $136.35
| Professional | | $102.26 | $120.30 | $136.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.66 / $95.55 / $204.26
| Professional | | $56.66 | $95.55 | $204.26 |