- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.30 / $78.30 / $108.12
| Facility | | $78.30 | $78.30 | $108.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.28 / $78.30 / $78.30
| Professional | | $37.28 | $78.30 | $78.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.39 / $46.85 / $111.48
| Facility | | $40.39 | $46.85 | $111.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.45 / $73.70 / $89.31
| Professional | | $71.45 | $73.70 | $89.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.10 / $37.28 / $39.77
| Professional | | $26.10 | $37.28 | $39.77 |