- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.38 / $100.38 / $100.38
| Facility | | $100.38 | $100.38 | $100.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.85 / $100.38 / $108.15
| Professional | | $82.85 | $100.38 | $108.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.01 / $152.54 / $156.33
| Professional | | $129.01 | $152.54 | $156.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.38 / $182.18 / $229.08
| Professional | | $180.38 | $182.18 | $229.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $76.93 / $108.15 / $706.68
| Facility | | $76.93 | $108.15 | $706.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.97 / $76.42 / $114.72
| Professional | | $54.97 | $76.42 | $114.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.89 / $76.42 / $137.97
| Professional | | $45.89 | $76.42 | $137.97 |