- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.36 / $126.36 / $162.01
| Facility | | $126.36 | $126.36 | $162.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.78 / $153.91 / $177.72
| Professional | | $133.78 | $153.91 | $177.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.60 / $216.63 / $216.63
| Facility | | $208.60 | $216.63 | $216.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.67 / $188.67 / $188.67
| Professional | | $188.67 | $188.67 | $188.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.26 / $173.25 / $232.98
| Professional | | $155.26 | $173.25 | $232.98 |