- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.68 / $130.68 / $130.68
| Facility | | $130.68 | $130.68 | $130.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.37 / $130.68 / $130.68
| Professional | | $66.37 | $130.68 | $130.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.13 / $132.13 / $155.46
| Professional | | $132.13 | $132.13 | $155.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.30 / $106.30 / $106.30
| Professional | | $106.30 | $106.30 | $106.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.03 / $100.03 / $154.65
| Facility | | $100.03 | $100.03 | $154.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.02 / $100.03 / $135.41
| Professional | | $73.02 | $100.03 | $135.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.94 / $77.56 / $110.03
| Professional | | $45.94 | $77.56 | $110.03 |