- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.19 / $126.57 / $215.17
| Facility | | $117.19 | $126.57 | $215.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.75 / $126.75 / $126.75
| Professional | | $126.75 | $126.75 | $126.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.70 / $193.51 / $306.88
| Facility | | $122.70 | $193.51 | $306.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.72 / $110.72 / $117.36
| Facility | | $110.72 | $110.72 | $117.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.36 / $117.36 / $117.36
| Professional | | $117.36 | $117.36 | $117.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.19 / $126.57 / $181.00
| Facility | | $117.19 | $126.57 | $181.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.47 / $117.19 / $117.36
| Professional | | $116.47 | $117.19 | $117.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.62 / $117.36 / $117.36
| Professional | | $105.62 | $117.36 | $117.36 |