- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $275.42
| Facility | | $141.25 | $141.25 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $85.11 / $275.42
| Professional | | $85.11 | $85.11 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $60.26
| Professional | | $30.20 | $44.67 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.49 / $138.04 / $323.59
| Facility | | $117.49 | $138.04 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.76 / $70.79 / $89.13
| Professional | | $7.76 | $70.79 | $89.13 |