- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.12 / $89.12 / $89.12
| Facility | | $89.12 | $89.12 | $89.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.12 / $94.83 / $154.05
| Professional | | $89.12 | $94.83 | $154.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.98 / $292.98 / $292.98
| Professional | | $292.98 | $292.98 | $292.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.95 / $125.46 / $175.90
| Professional | | $88.95 | $125.46 | $175.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.84 / $81.84 / $81.84
| Professional | | $81.84 | $81.84 | $81.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.83 / $160.19 / $312.14
| Professional | | $101.83 | $160.19 | $312.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.86 / $149.18 / $334.21
| Professional | | $106.86 | $149.18 | $334.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.97 / $91.16 / $143.88
| Professional | | $75.97 | $91.16 | $143.88 |