- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.59 / $137.87 / $196.98
| Facility | | $120.59 | $137.87 | $196.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.52 / $128.40 / $270.00
| Professional | | $111.52 | $128.40 | $270.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.30 / $249.77 / $466.60
| Facility | | $233.30 | $249.77 | $466.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.85 / $117.47 / $192.68
| Professional | | $111.85 | $117.47 | $192.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.55 / $152.55 / $153.72
| Facility | | $152.55 | $152.55 | $153.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.36 / $134.37 / $162.62
| Professional | | $111.36 | $134.37 | $162.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.41 / $116.39 / $185.53
| Professional | | $83.41 | $116.39 | $185.53 |