- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.61 / $105.33 / $138.52
| Facility | | $79.61 | $105.33 | $138.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.33 / $105.33 / $105.33
| Professional | | $105.33 | $105.33 | $105.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.75 / $51.75 / $102.65
| Facility | | $51.75 | $51.75 | $102.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.48 / $105.33 / $114.35
| Professional | | $91.48 | $105.33 | $114.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.80 / $94.80 / $94.80
| Facility | | $94.80 | $94.80 | $94.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.26 / $63.20 / $105.38
| Professional | | $44.26 | $63.20 | $105.38 |