- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.33 / $105.33 / $487.21
| Facility | | $105.33 | $105.33 | $487.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.33 / $105.33 / $105.33
| Professional | | $105.33 | $105.33 | $105.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.33 / $329.68 / $721.51
| Professional | | $105.33 | $329.68 | $721.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.55 / $134.55 / $134.55
| Facility | | $134.55 | $134.55 | $134.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.48 / $91.48 / $114.35
| Professional | | $91.48 | $91.48 | $114.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.47 / $255.47 / $255.47
| Professional | | $255.47 | $255.47 | $255.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.24 / $47.40 / $72.44
| Professional | | $44.24 | $47.40 | $72.44 |