- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $138.04 / $354.81
| Facility | | $104.71 | $138.04 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $125.89 / $177.83
| Professional | | $102.33 | $125.89 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $151.36 / $223.87
| Professional | | $95.50 | $151.36 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $151.36 / $288.40
| Professional | | $104.71 | $151.36 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $239.88 / $239.88
| Professional | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $154.88 / $177.83
| Professional | | $125.89 | $154.88 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $158.49 / $338.84
| Professional | | $107.15 | $158.49 | $338.84 |