- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.75 / $139.75 / $167.70
| Facility | | $139.75 | $139.75 | $167.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.00 / $139.75 / $139.75
| Professional | | $13.00 | $139.75 | $139.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.68 / $6.68 / $6.68
| Professional | | $6.68 | $6.68 | $6.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.77 / $130.77 / $130.77
| Professional | | $130.77 | $130.77 | $130.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.69 / $77.05 / $101.71
| Professional | | $69.69 | $77.05 | $101.71 |