- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.48 / $125.89 / $125.89
| Facility | | $52.48 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $85.11 / $123.03
| Professional | | $66.07 | $85.11 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $109.65 / $138.04
| Professional | | $97.72 | $109.65 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $144.54 / $194.98
| Professional | | $123.03 | $144.54 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $186.21
| Professional | | $147.91 | $147.91 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $125.89 / $125.89
| Professional | | $114.82 | $125.89 | $125.89 |