- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.49 / $198.91 / $280.98
| Facility | | $86.49 | $198.91 | $280.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.14 / $100.14 / $100.14
| Professional | | $100.14 | $100.14 | $100.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.79 / $113.79 / $113.79
| Professional | | $113.79 | $113.79 | $113.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.62 / $106.62 / $106.62
| Facility | | $106.62 | $106.62 | $106.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.55 / $101.55 / $101.55
| Professional | | $101.55 | $101.55 | $101.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.63 / $109.16 / $138.55
| Professional | | $95.63 | $109.16 | $138.55 |