- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $92.72 / $195.64 / $856.84
| Facility | | $92.72 | $195.64 | $856.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.75 / $92.72 / $109.50
| Professional | | $56.75 | $92.72 | $109.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.48 / $106.44 / $176.32
| Professional | | $86.48 | $106.44 | $176.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.46 / $142.46 / $142.46
| Facility | | $142.46 | $142.46 | $142.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.55 / $105.05 / $174.97
| Professional | | $80.55 | $105.05 | $174.97 |