- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.71 / $153.71 / $153.71
| Facility | | $153.71 | $153.71 | $153.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.38 / $109.48 / $133.97
| Professional | | $96.38 | $109.48 | $133.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.89 / $148.40 / $233.91
| Professional | | $101.89 | $148.40 | $233.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.20 / $184.60 / $308.26
| Professional | | $121.20 | $184.60 | $308.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.64 / $190.01 / $360.01
| Professional | | $116.64 | $190.01 | $360.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.86 / $168.32 / $329.41
| Professional | | $121.86 | $168.32 | $329.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.03 / $94.62 / $120.43
| Professional | | $85.03 | $94.62 | $120.43 |