- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.82 / $134.82 / $186.18
| Facility | | $134.82 | $134.82 | $186.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.20 / $134.82 / $134.82
| Professional | | $64.20 | $134.82 | $134.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.98 / $121.98 / $121.98
| Facility | | $121.98 | $121.98 | $121.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.30 / $128.40 / $144.44
| Professional | | $96.30 | $128.40 | $144.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69.55 / $80.68 / $159.97
| Facility | | $69.55 | $80.68 | $159.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $96.30 / $96.30 / $96.30
| Facility | | $96.30 | $96.30 | $96.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.94 / $64.20 / $107.00
| Professional | | $44.94 | $64.20 | $107.00 |