- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.90 / $75.90 / $159.47
| Facility | | $75.90 | $75.90 | $159.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.90 / $77.88 / $88.69
| Professional | | $75.90 | $77.88 | $88.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.99 / $142.72 / $159.47
| Facility | | $125.99 | $142.72 | $159.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.91 / $96.39 / $130.12
| Professional | | $79.91 | $96.39 | $130.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.61 / $175.43 / $239.22
| Facility | | $119.61 | $175.43 | $239.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.56 / $175.43 / $215.30
| Professional | | $135.56 | $175.43 | $215.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99.66 / $99.66 / $159.47
| Facility | | $99.66 | $99.66 | $159.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.75 / $99.66 / $163.61
| Professional | | $72.75 | $99.66 | $163.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.04 / $79.56 / $119.88
| Professional | | $53.04 | $79.56 | $119.88 |