- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.72 / $137.68 / $137.68
| Facility | | $131.72 | $137.68 | $137.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.45 / $131.72 / $137.68
| Professional | | $106.45 | $131.72 | $137.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.76 / $56.76 / $56.76
| Professional | | $56.76 | $56.76 | $56.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.67 / $60.91 / $78.67
| Professional | | $28.67 | $60.91 | $78.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $50.00
| Professional | | $40.00 | $40.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.20 / $23.20 / $23.20
| Professional | | $23.20 | $23.20 | $23.20 |