- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.32 / $118.32 / $118.32
| Facility | | $118.32 | $118.32 | $118.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.63 / $100.87 / $118.79
| Professional | | $93.63 | $100.87 | $118.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.69 / $156.26 / $183.84
| Professional | | $128.69 | $156.26 | $183.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $174.68
| Professional | | $141.06 | $141.06 | $174.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.45 / $109.43 / $142.84
| Facility | | $94.45 | $109.43 | $142.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.68 / $142.32 / $882.23
| Professional | | $113.68 | $142.32 | $882.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.27 / $120.37 / $182.50
| Professional | | $110.27 | $120.37 | $182.50 |