- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.30 / $181.72 / $215.37
| Facility | | $127.30 | $181.72 | $215.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.51 / $105.00 / $120.00
| Professional | | $81.51 | $105.00 | $120.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.07 / $42.70 / $63.92
| Professional | | $38.07 | $42.70 | $63.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.73 / $105.73 / $132.16
| Professional | | $105.73 | $105.73 | $132.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.00 / $307.00 / $307.00
| Professional | | $307.00 | $307.00 | $307.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.68 / $21.68 / $21.68
| Facility | | $21.68 | $21.68 | $21.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.32 / $33.32 / $33.32
| Professional | | $33.32 | $33.32 | $33.32 |