- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.91 / $223.10 / $247.48
| Facility | | $121.91 | $223.10 | $247.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.31 / $96.31 / $134.10
| Professional | | $96.31 | $96.31 | $134.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.47 / $164.58 / $164.58
| Facility | | $158.47 | $164.58 | $164.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.58 / $164.58 / $164.58
| Professional | | $164.58 | $164.58 | $164.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.23 / $83.20 / $102.75
| Facility | | $79.23 | $83.20 | $102.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Professional | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.20 / $75.26 / $225.78
| Professional | | $51.20 | $75.26 | $225.78 |