- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.68 / $109.68 / $171.37
| Facility | | $109.68 | $109.68 | $171.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.94 / $159.46 / $171.37
| Professional | | $102.94 | $159.46 | $171.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.63 / $151.63 / $151.63
| Facility | | $151.63 | $151.63 | $151.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.63 / $151.63 / $151.63
| Professional | | $151.63 | $151.63 | $151.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.73 / $67.73 / $67.73
| Facility | | $67.73 | $67.73 | $67.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.58 / $57.58 / $67.73
| Professional | | $57.58 | $57.58 | $67.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.85 / $97.63 / $133.72
| Professional | | $57.85 | $97.63 | $133.72 |