- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.45 / $94.15 / $104.44
| Facility | | $51.45 | $94.15 | $104.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.65 / $94.15 / $104.44
| Professional | | $40.65 | $94.15 | $104.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.13 / $136.13 / $136.13
| Facility | | $136.13 | $136.13 | $136.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.13 / $136.13 / $136.13
| Professional | | $136.13 | $136.13 | $136.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.44 / $39.02 / $126.87
| Facility | | $33.44 | $39.02 | $126.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.09 / $23.41 / $88.35
| Professional | | $22.09 | $23.41 | $88.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.61 / $30.87 / $87.47
| Professional | | $21.61 | $30.87 | $87.47 |