- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.43 / $131.83 / $138.04
| Facility | | $79.43 | $131.83 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $131.83 / $138.04
| Professional | | $107.15 | $131.83 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $42.66 / $54.95
| Professional | | $16.22 | $42.66 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $72.44 / $151.36
| Professional | | $56.23 | $72.44 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $61.66 / $61.66
| Professional | | $61.66 | $61.66 | $61.66 |