- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.63 / $198.66 / $263.39
| Facility | | $139.63 | $198.66 | $263.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.00 / $133.47 / $240.28
| Professional | | $90.00 | $133.47 | $240.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.43 / $119.43 / $119.43
| Professional | | $119.43 | $119.43 | $119.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.13 / $131.13 / $131.13
| Professional | | $131.13 | $131.13 | $131.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.45 / $133.47 / $133.47
| Professional | | $126.45 | $133.47 | $133.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.91 / $140.50 / $140.50
| Professional | | $115.91 | $140.50 | $140.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.47 / $133.47 / $133.47
| Professional | | $133.47 | $133.47 | $133.47 |