- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.15 / $104.46 / $117.84
| Facility | | $104.15 | $104.46 | $117.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.62 / $104.15 / $143.60
| Professional | | $84.62 | $104.15 | $143.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.41 / $201.50 / $353.76
| Facility | | $173.41 | $201.50 | $353.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.61 / $105.61 / $145.74
| Professional | | $105.61 | $105.61 | $145.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.01 / $144.01 / $144.01
| Facility | | $144.01 | $144.01 | $144.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.13 / $137.32 / $148.33
| Professional | | $105.13 | $137.32 | $148.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.09 / $96.05 / $145.79
| Professional | | $72.09 | $96.05 | $145.79 |