- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.32 / $118.32 / $133.69
| Facility | | $118.32 | $118.32 | $133.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.73 / $116.12 / $173.60
| Professional | | $92.73 | $116.12 | $173.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.36 / $190.60 / $224.68
| Professional | | $182.36 | $190.60 | $224.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.64 / $140.21 / $229.10
| Professional | | $97.64 | $140.21 | $229.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.02 / $147.05 / $250.42
| Professional | | $101.02 | $147.05 | $250.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.50 / $162.69 / $282.95
| Professional | | $126.50 | $162.69 | $282.95 |