- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.14 / $100.14 / $204.84
| Facility | | $100.14 | $100.14 | $204.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.50 / $100.14 / $125.18
| Professional | | $76.50 | $100.14 | $125.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.81 / $106.62 / $106.62
| Facility | | $73.81 | $106.62 | $106.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.62 / $106.62 / $106.62
| Professional | | $106.62 | $106.62 | $106.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $70.81 / $78.68
| Professional | | $20.00 | $70.81 | $78.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.60 / $105.77 / $115.46
| Professional | | $96.60 | $105.77 | $115.46 |