- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.81 / $141.81 / $210.14
| Facility | | $141.81 | $141.81 | $210.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.02 / $141.81 / $141.81
| Professional | | $72.02 | $141.81 | $141.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.92 / $103.92 / $103.92
| Facility | | $103.92 | $103.92 | $103.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.09 / $126.61 / $126.61
| Professional | | $86.09 | $126.61 | $126.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.73 / $109.77 / $225.05
| Facility | | $68.73 | $109.77 | $225.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.12 / $104.90 / $131.13
| Professional | | $53.12 | $104.90 | $131.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.29 / $54.70 / $127.36
| Professional | | $38.29 | $54.70 | $127.36 |