- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.14 / $280.12 / $280.12
| Facility | | $123.14 | $280.12 | $280.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.15 / $42.38 / $53.82
| Professional | | $32.15 | $42.38 | $53.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.23 / $68.23 / $68.23
| Facility | | $68.23 | $68.23 | $68.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.31 / $50.31 / $50.31
| Professional | | $50.31 | $50.31 | $50.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.68 / $62.26 / $112.14
| Professional | | $42.68 | $62.26 | $112.14 |