- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.33 / $157.33 / $165.77
| Facility | | $149.33 | $157.33 | $165.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.45 / $25.81 / $40.28
| Professional | | $7.45 | $25.81 | $40.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $59.96 / $142.05 / $183.62
| Facility | | $59.96 | $142.05 | $183.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.09 / $23.62 / $48.52
| Professional | | $16.09 | $23.62 | $48.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.62 / $23.62 / $48.52
| Professional | | $23.62 | $23.62 | $48.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.72 / $27.63 / $58.40
| Professional | | $13.72 | $27.63 | $58.40 |