- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.52 / $102.52 / $102.52
| Facility | | $102.52 | $102.52 | $102.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.84 / $102.52 / $102.52
| Professional | | $96.84 | $102.52 | $102.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.83 / $92.10 / $115.12
| Professional | | $86.83 | $92.10 | $115.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.26 / $202.43 / $435.94
| Professional | | $104.26 | $202.43 | $435.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.08 / $133.68 / $236.26
| Professional | | $112.08 | $133.68 | $236.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.00 / $442.00 / $5,940.00
| Facility | | $165.00 | $442.00 | $5,940.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.30 / $128.66 / $245.67
| Professional | | $66.30 | $128.66 | $245.67 |