- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $82.08 / $82.08 / $82.08
| Facility | | $82.08 | $82.08 | $82.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.08 / $103.66 / $103.66
| Professional | | $82.08 | $103.66 | $103.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.48 / $124.71 / $127.81
| Professional | | $105.48 | $124.71 | $127.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.63 / $145.06 / $182.40
| Professional | | $143.63 | $145.06 | $182.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.25 / $103.66 / $584.39
| Facility | | $54.25 | $103.66 | $584.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.95 / $82.44 / $91.60
| Professional | | $44.95 | $82.44 | $91.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.64 / $82.44 / $130.76
| Professional | | $36.64 | $82.44 | $130.76 |