- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.21 / $100.21 / $105.69
| Facility | | $100.21 | $100.21 | $105.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.21 / $100.21 / $1,485.90
| Professional | | $100.21 | $100.21 | $1,485.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.06 / $163.74 / $215.13
| Facility | | $129.06 | $163.74 | $215.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.38 / $86.38 / $86.38
| Professional | | $86.38 | $86.38 | $86.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $232.59 / $326.18 / $562.94
| Facility | | $232.59 | $326.18 | $562.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.38 / $86.38 / $86.38
| Professional | | $86.38 | $86.38 | $86.38 |