- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.61 / $146.96 / $171.55
| Facility | | $137.61 | $146.96 | $171.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.56 / $146.96 / $146.96
| Professional | | $81.56 | $146.96 | $146.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.60 / $107.60 / $117.07
| Facility | | $107.60 | $107.60 | $117.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.53 / $168.58 / $307.20
| Facility | | $58.53 | $168.58 | $307.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.17 / $141.94 / $185.00
| Professional | | $93.17 | $141.94 | $185.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.96 / $180.11 / $303.37
| Professional | | $100.96 | $180.11 | $303.37 |