- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.18 / $144.18 / $199.11
| Facility | | $144.18 | $144.18 | $199.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.66 / $136.16 / $144.18
| Professional | | $68.66 | $136.16 | $144.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.99 / $137.32 / $154.49
| Professional | | $102.99 | $137.32 | $154.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.38 / $147.71 / $214.86
| Facility | | $74.38 | $147.71 | $214.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.06 / $68.66 / $107.56
| Professional | | $48.06 | $68.66 | $107.56 |