- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.71 / $105.71 / $177.34
| Facility | | $105.71 | $105.71 | $177.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.79 / $105.71 / $106.96
| Professional | | $83.79 | $105.71 | $106.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.51 / $237.48 / $260.38
| Professional | | $197.51 | $237.48 | $260.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.57 / $196.02 / $274.11
| Professional | | $135.57 | $196.02 | $274.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.71 / $147.78 / $256.38
| Facility | | $105.71 | $147.78 | $256.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.55 / $208.28 / $907.42
| Professional | | $114.55 | $208.28 | $907.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.55 / $187.45 / $265.80
| Professional | | $114.55 | $187.45 | $265.80 |