- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.93 / $133.85 / $208.85
| Facility | | $117.93 | $133.85 | $208.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.93 / $141.34 / $182.56
| Professional | | $117.93 | $141.34 | $182.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.89 / $171.13 / $316.57
| Professional | | $119.89 | $171.13 | $316.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.17 / $246.17 / $475.52
| Facility | | $246.17 | $246.17 | $475.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.40 / $173.32 / $242.31
| Professional | | $130.40 | $173.32 | $242.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.67 / $260.50 / $260.50
| Professional | | $193.67 | $260.50 | $260.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.30 / $176.22 / $386.15
| Professional | | $122.30 | $176.22 | $386.15 |