- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.25 / $71.25 / $71.25
| Facility | | $71.25 | $71.25 | $71.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.41 / $60.53 / $71.25
| Professional | | $42.41 | $60.53 | $71.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $96.47 / $100.20 / $204.59
| Facility | | $96.47 | $100.20 | $204.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.17 / $102.05 / $105.21
| Professional | | $84.17 | $102.05 | $105.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.13 / $71.25 / $146.61
| Facility | | $23.13 | $71.25 | $146.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.35 / $382.72 / $382.72
| Professional | | $103.35 | $382.72 | $382.72 |