- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.45 / $322.83 / $435.02
| Facility | | $112.45 | $322.83 | $435.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.45 / $112.45 / $112.45
| Professional | | $112.45 | $112.45 | $112.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.46 / $189.87 / $321.05
| Professional | | $112.46 | $189.87 | $321.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.09 / $106.09 / $112.45
| Facility | | $106.09 | $106.09 | $112.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.58 / $95.58 / $112.45
| Professional | | $95.58 | $95.58 | $112.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $112.45 / $182.26
| Professional | | $102.33 | $112.45 | $182.26 |