- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.55 / $105.55 / $105.55
| Facility | | $105.55 | $105.55 | $105.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.04 / $76.04 / $105.55
| Professional | | $76.04 | $76.04 | $105.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.63 / $160.38 / $164.37
| Professional | | $135.63 | $160.38 | $164.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.63 / $172.33 / $216.69
| Professional | | $170.63 | $172.33 | $216.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.28 / $105.55 / $659.83
| Facility | | $61.28 | $105.55 | $659.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.35 / $70.13 / $115.59
| Professional | | $57.35 | $70.13 | $115.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.11 / $70.13 / $150.27
| Professional | | $42.11 | $70.13 | $150.27 |