- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.53 / $148.09 / $418.55
| Facility | | $117.53 | $148.09 | $418.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.28 / $117.53 / $117.53
| Professional | | $113.28 | $117.53 | $117.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Facility | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Professional | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.50 / $521.65 / $531.00
| Facility | | $139.50 | $521.65 | $531.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.00 / $118.00 / $120.36
| Professional | | $118.00 | $118.00 | $120.36 |