- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.43 / $65.43 / $65.43
| Facility | | $65.43 | $65.43 | $65.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.02 / $54.02 / $65.43
| Professional | | $54.02 | $54.02 | $65.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.08 / $99.41 / $101.89
| Professional | | $84.08 | $99.41 | $101.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.25 / $105.29 / $132.40
| Professional | | $104.25 | $105.29 | $132.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.14 / $65.43 / $472.21
| Facility | | $50.14 | $65.43 | $472.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.83 / $52.35 / $92.22
| Professional | | $35.83 | $52.35 | $92.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.91 / $44.87 / $74.78
| Professional | | $29.91 | $44.87 | $74.78 |