- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.83 / $158.49 / $271.52
| Facility | | $134.83 | $158.49 | $271.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.75 / $123.57 / $134.83
| Professional | | $101.75 | $123.57 | $134.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.83 / $134.83 / $134.83
| Professional | | $134.83 | $134.83 | $134.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.32 / $148.32 / $148.32
| Professional | | $148.32 | $148.32 | $148.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.94 / $118.00 / $142.76
| Professional | | $81.94 | $118.00 | $142.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.11 / $158.62 / $158.91
| Professional | | $131.11 | $158.62 | $158.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.34 / $131.34 / $131.34
| Professional | | $131.34 | $131.34 | $131.34 |