- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.62 / $110.57 / $178.34
| Facility | | $94.62 | $110.57 | $178.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.56 / $50.01 / $66.03
| Professional | | $40.56 | $50.01 | $66.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.25 / $166.25 / $166.25
| Professional | | $166.25 | $166.25 | $166.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $70.00
| Professional | | $50.00 | $50.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $90.00 / $90.00
| Facility | | $90.00 | $90.00 | $90.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.37 / $97.37 / $166.25
| Professional | | $97.37 | $97.37 | $166.25 |