- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.46 / $131.34 / $251.63
| Facility | | $117.46 | $131.34 | $251.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.57 / $116.76 / $119.58
| Professional | | $112.57 | $116.76 | $119.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.36 / $197.63 / $374.58
| Facility | | $120.36 | $197.63 | $374.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.24 / $117.24 / $119.58
| Professional | | $117.24 | $117.24 | $119.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.58 / $119.58 / $119.58
| Facility | | $119.58 | $119.58 | $119.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.58 / $119.58 / $119.58
| Professional | | $119.58 | $119.58 | $119.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.24 / $117.24 / $128.96
| Professional | | $117.24 | $117.24 | $128.96 |