- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.27 / $126.27 / $126.27
| Facility | | $126.27 | $126.27 | $126.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.28 / $129.43 / $157.46
| Professional | | $120.28 | $129.43 | $157.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.83 / $177.46 / $248.81
| Professional | | $125.83 | $177.46 | $248.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.76 / $115.76 / $115.76
| Professional | | $115.76 | $115.76 | $115.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.05 / $226.62 / $441.56
| Professional | | $144.05 | $226.62 | $441.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.47 / $203.75 / $454.04
| Professional | | $145.47 | $203.75 | $454.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.30 / $123.96 / $195.65
| Professional | | $103.30 | $123.96 | $195.65 |