- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.35 / $121.35 / $165.13
| Facility | | $121.35 | $121.35 | $165.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.53 / $109.23 / $139.24
| Professional | | $93.53 | $109.23 | $139.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.74 / $103.10 / $232.42
| Professional | | $38.74 | $103.10 | $232.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.58 / $193.40 / $208.45
| Facility | | $184.58 | $193.40 | $208.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.74 / $100.27 / $226.92
| Professional | | $41.74 | $100.27 | $226.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.74 / $223.74 / $223.74
| Facility | | $223.74 | $223.74 | $223.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.58 / $104.19 / $243.90
| Professional | | $58.58 | $104.19 | $243.90 |