- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.73 / $100.73 / $157.38
| Facility | | $100.73 | $100.73 | $157.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.84 / $130.25 / $157.38
| Professional | | $88.84 | $130.25 | $157.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.28 / $139.28 / $139.28
| Facility | | $139.28 | $139.28 | $139.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.28 / $139.28 / $139.28
| Professional | | $139.28 | $139.28 | $139.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.25 / $113.25 / $113.25
| Facility | | $113.25 | $113.25 | $113.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.67 / $82.67 / $113.25
| Professional | | $82.67 | $82.67 | $113.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.16 / $89.67 / $141.97
| Professional | | $53.16 | $89.67 | $141.97 |