- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.41 / $108.57 / $141.62
| Facility | | $94.41 | $108.57 | $141.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.62 / $108.57 / $108.57
| Professional | | $88.62 | $108.57 | $108.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.21 / $47.21 / $47.21
| Professional | | $47.21 | $47.21 | $47.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.07 / $177.26 / $238.48
| Facility | | $146.07 | $177.26 | $238.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.20 / $136.00 / $149.60
| Professional | | $95.20 | $136.00 | $149.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.47 / $212.99 / $249.86
| Facility | | $200.47 | $212.99 | $249.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.65 / $39.65 / $93.09
| Professional | | $39.65 | $39.65 | $93.09 |