- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.43 / $209.41 / $232.29
| Facility | | $114.43 | $209.41 | $232.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.40 / $90.40 / $90.40
| Professional | | $90.40 | $90.40 | $90.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.43 / $114.43 / $114.43
| Facility | | $114.43 | $114.43 | $114.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.43 / $114.43 / $114.43
| Professional | | $114.43 | $114.43 | $114.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.38 / $78.09 / $86.80
| Facility | | $74.38 | $78.09 | $86.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.75 / $131.75 / $164.68
| Professional | | $131.75 | $131.75 | $164.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.06 / $57.22 / $183.61
| Professional | | $48.06 | $57.22 | $183.61 |