- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.66 / $121.66 / $127.06
| Facility | | $121.66 | $121.66 | $127.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.25 / $122.36 / $146.75
| Professional | | $100.25 | $122.36 | $146.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.70 / $178.52 / $262.52
| Professional | | $115.70 | $178.52 | $262.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.06 / $27.06 / $27.06
| Facility | | $27.06 | $27.06 | $27.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.85 / $170.63 / $265.70
| Professional | | $90.85 | $170.63 | $265.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.66 / $137.63 / $1,007.00
| Professional | | $131.66 | $137.63 | $1,007.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.07 / $146.87 / $328.51
| Professional | | $103.07 | $146.87 | $328.51 |