- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.43 / $142.19 / $170.63
| Facility | | $117.43 | $142.19 | $170.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.74 / $130.16 / $152.22
| Professional | | $100.74 | $130.16 | $152.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.77 / $150.41 / $227.85
| Professional | | $116.77 | $150.41 | $227.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.43 / $107.43 / $107.43
| Professional | | $107.43 | $107.43 | $107.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.79 / $187.31 / $330.27
| Professional | | $103.79 | $187.31 | $330.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.70 / $187.80 / $331.76
| Professional | | $167.70 | $187.80 | $331.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.63 / $164.60 / $209.50
| Professional | | $149.63 | $164.60 | $209.50 |