- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.47 / $104.47 / $104.47
| Facility | | $104.47 | $104.47 | $104.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.23 / $104.47 / $184.82
| Professional | | $100.23 | $104.47 | $184.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.00 / $138.66 / $223.73
| Professional | | $110.00 | $138.66 | $223.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.40 / $149.11 / $164.62
| Facility | | $86.40 | $149.11 | $164.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.85 / $126.93 / $149.11
| Professional | | $108.85 | $126.93 | $149.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.92 / $146.26 / $331.49
| Facility | | $93.92 | $146.26 | $331.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.00 / $122.00 / $122.00
| Professional | | $122.00 | $122.00 | $122.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.20 / $100.60 / $140.94
| Professional | | $70.20 | $100.60 | $140.94 |