- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.66 / $108.66 / $171.68
| Facility | | $108.66 | $108.66 | $171.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.93 / $108.66 / $126.36
| Professional | | $92.93 | $108.66 | $126.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.00 / $61.00 / $79.91
| Professional | | $61.00 | $61.00 | $79.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.08 / $78.08 / $114.08
| Professional | | $78.08 | $78.08 | $114.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.03 / $109.50 / $225.32
| Professional | | $104.03 | $109.50 | $225.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.22 / $109.21 / $290.08
| Professional | | $75.22 | $109.21 | $290.08 |