- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.46 / $209.02 / $273.70
| Facility | | $133.46 | $209.02 | $273.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.00 / $133.47 / $148.15
| Professional | | $113.00 | $133.47 | $148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.89 / $56.89 / $71.54
| Facility | | $56.89 | $56.89 | $71.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.18 / $131.13 / $131.13
| Facility | | $89.18 | $131.13 | $131.13 |
- 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
- $117.08 / $132.30 / $140.50
| Professional | | $117.08 | $132.30 | $140.50 |