- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.63 / $121.54 / $217.36
| Facility | | $103.63 | $121.54 | $217.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.13 / $77.45 / $108.48
| Professional | | $63.13 | $77.45 | $108.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.38 / $79.13 / $98.45
| Professional | | $60.38 | $79.13 | $98.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $82.00 / $194.54
| Professional | | $45.00 | $82.00 | $194.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.84 / $125.90 / $175.27
| Professional | | $104.84 | $125.90 | $175.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.69 / $121.59 / $245.89
| Professional | | $76.69 | $121.59 | $245.89 |