- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $393.60 / $393.60 / $393.60
| Facility | | $393.60 | $393.60 | $393.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.57 / $102.61 / $123.35
| Professional | | $85.57 | $102.61 | $123.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.84 / $110.79 / $159.16
| Professional | | $106.84 | $110.79 | $159.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.61 / $116.48 / $162.75
| Facility | | $102.61 | $116.48 | $162.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.29 / $139.25 / $159.13
| Professional | | $131.29 | $139.25 | $159.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $146.00
| Professional | | $32.34 | $32.34 | $146.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.61 / $121.89 / $147.96
| Professional | | $103.61 | $121.89 | $147.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.34 / $131.51 / $175.36
| Professional | | $92.34 | $131.51 | $175.36 |