- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.16 / $144.16 / $144.16
| Facility | | $144.16 | $144.16 | $144.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.23 / $102.18 / $144.16
| Professional | | $68.23 | $102.18 | $144.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.78 / $100.78 / $100.78
| Professional | | $100.78 | $100.78 | $100.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.16 / $85.16 / $156.57
| Facility | | $85.16 | $85.16 | $156.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.17 / $85.16 / $137.10
| Professional | | $62.17 | $85.16 | $137.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.32 / $67.98 / $107.54
| Professional | | $45.32 | $67.98 | $107.54 |