- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.25 / $113.25 / $305.37
| Facility | | $113.25 | $113.25 | $305.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.04 / $159.04 / $251.51
| Professional | | $77.04 | $159.04 | $251.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.09 / $105.99 / $161.86
| Professional | | $90.09 | $105.99 | $161.86 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $135.13 / $158.99 / $242.79
| Professional | 50 | $135.13 | $158.99 | $242.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.39 / $181.07 / $423.75
| Professional | | $102.39 | $181.07 | $423.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.81 / $269.58 / $432.78
| Professional | | $101.81 | $269.58 | $432.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.25 / $113.25 / $305.37
| Facility | | $113.25 | $113.25 | $305.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.81 / $153.15 / $383.57
| Professional | | $81.81 | $153.15 | $383.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.50 / $292.64 / $453.06
| Professional | | $181.50 | $292.64 | $453.06 |