- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.81 / $86.81 / $86.81
| Facility | | $86.81 | $86.81 | $86.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.34 / $86.81 / $112.85
| Professional | | $75.34 | $86.81 | $112.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.29 / $85.56 / $86.43
| Professional | | $81.29 | $85.56 | $86.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.84 / $160.44 / $243.36
| Professional | | $81.84 | $160.44 | $243.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.81 / $147.58 / $220.13
| Facility | | $86.81 | $147.58 | $220.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.36 / $193.03 / $613.55
| Professional | | $153.36 | $193.03 | $613.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.64 / $158.36 / $243.36
| Facility | | $113.64 | $158.36 | $243.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.11 / $158.72 / $243.36
| Professional | | $119.11 | $158.72 | $243.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.65 / $191.70 / $235.12
| Professional | | $146.65 | $191.70 | $235.12 |