- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $129.47
| Facility | | $129.47 | $129.47 | $129.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.30 / $131.19 / $162.41
| Professional | | $105.30 | $131.19 | $162.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.62 / $174.50 / $184.82
| Professional | | $138.62 | $174.50 | $184.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.15 / $83.15 / $83.15
| Facility | | $83.15 | $83.15 | $83.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.70 / $70.68 / $158.74
| Professional | | $60.70 | $70.68 | $158.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.36 / $970.44 / $970.44
| Facility | | $207.36 | $970.44 | $970.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.72 / $107.32 / $153.44
| Professional | | $68.72 | $107.32 | $153.44 |