- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.58 / $102.58 / $145.50
| Facility | | $102.58 | $102.58 | $145.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.72 / $102.58 / $126.07
| Professional | | $96.72 | $102.58 | $126.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.02 / $140.02 / $140.02
| Facility | | $140.02 | $140.02 | $140.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.65 / $58.65 / $58.65
| Professional | | $58.65 | $58.65 | $58.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.11 / $118.67 / $118.67
| Facility | | $114.11 | $118.67 | $118.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.36 / $149.28 / $188.71
| Professional | | $94.36 | $149.28 | $188.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $50.00
| Professional | | $40.00 | $40.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |