- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.64 / $105.64 / $129.47
| Facility | | $105.64 | $105.64 | $129.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.34 / $105.64 / $131.18
| Professional | | $92.34 | $105.64 | $131.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.34 / $125.43 / $170.47
| Professional | | $100.34 | $125.43 | $170.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.07 / $139.07 / $139.07
| Facility | | $139.07 | $139.07 | $139.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.43 / $107.43 / $562.83
| Professional | | $107.43 | $107.43 | $562.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $146.38
| Professional | | $32.34 | $32.34 | $146.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.59 / $137.79 / $204.11
| Professional | | $108.59 | $137.79 | $204.11 |