- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.28 / $174.42 / $194.40
| Facility | | $157.28 | $174.42 | $194.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.56 / $35.18 / $176.40
| Professional | | $24.56 | $35.18 | $176.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.82 / $70.70 / $79.23
| Professional | | $52.82 | $70.70 | $79.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.43 / $83.43 / $122.47
| Professional | | $83.43 | $83.43 | $122.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.56 / $84.00 / $191.20
| Facility | | $24.56 | $84.00 | $191.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $50.88 / $289.44
| Professional | | $21.05 | $50.88 | $289.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.74 / $38.60 / $60.18
| Professional | | $14.74 | $38.60 | $60.18 |