- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.53 / $93.53 / $93.53
| Facility | | $93.53 | $93.53 | $93.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.41 / $88.34 / $93.53
| Professional | | $76.41 | $88.34 | $93.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.18 / $142.10 / $145.63
| Professional | | $120.18 | $142.10 | $145.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.38 / $148.85 / $187.17
| Professional | | $147.38 | $148.85 | $187.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.69 / $93.53 / $592.25
| Facility | | $37.69 | $93.53 | $592.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.22 / $62.92 / $102.43
| Professional | | $51.22 | $62.92 | $102.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.78 / $56.68 / $102.43
| Professional | | $37.78 | $56.68 | $102.43 |