- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.66 / $67.66 / $67.66
| Facility | | $67.66 | $67.66 | $67.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.58 / $65.41 / $74.73
| Professional | | $32.58 | $65.41 | $74.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.36 / $169.53 / $179.65
| Facility | | $154.36 | $169.53 | $179.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.88 / $76.48 / $104.43
| Professional | | $36.88 | $76.48 | $104.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.12 / $101.12 / $101.12
| Facility | | $101.12 | $101.12 | $101.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.59 / $37.59 / $37.59
| Professional | | $37.59 | $37.59 | $37.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.65 / $39.07 / $57.38
| Professional | | $33.65 | $39.07 | $57.38 |