- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.87 / $130.87 / $130.87
| Facility | | $130.87 | $130.87 | $130.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.01 / $71.45 / $101.04
| Professional | | $48.01 | $71.45 | $101.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.11 / $97.54 / $115.45
| Professional | | $86.11 | $97.54 | $115.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.83 / $95.04 / $127.44
| Professional | | $66.83 | $95.04 | $127.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.34 / $146.08 / $361.45
| Professional | | $71.34 | $146.08 | $361.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.13 / $88.59 / $170.94
| Professional | | $72.13 | $88.59 | $170.94 |