- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $75.86
| Facility | | $60.26 | $60.26 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.74 / $51.29 / $81.28
| Professional | | $40.74 | $51.29 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $69.18 / $102.33
| Professional | | $58.88 | $69.18 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $109.65
| Professional | | $32.36 | $33.11 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $87.10 / $104.71
| Professional | | $64.57 | $87.10 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $79.43 / $109.65
| Professional | | $42.66 | $79.43 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $75.86 / $109.65
| Professional | | $63.10 | $75.86 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $4,466.84 / $5,128.61
| Facility | | $1,071.52 | $4,466.84 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $61.66 / $104.71
| Professional | | $47.86 | $61.66 | $104.71 |