- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.16 / $105.16 / $105.16
| Facility | | $105.16 | $105.16 | $105.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.60 / $100.18 / $126.49
| Professional | | $49.60 | $100.18 | $126.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.81 / $254.05 / $266.22
| Facility | | $235.81 | $254.05 | $266.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.19 / $117.30 / $158.58
| Professional | | $54.19 | $117.30 | $158.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.01 / $184.01 / $184.01
| Facility | | $184.01 | $184.01 | $184.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.66 / $57.66 / $57.66
| Professional | | $57.66 | $57.66 | $57.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.94 / $59.93 / $90.27
| Professional | | $49.94 | $59.93 | $90.27 |