- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.68 / $102.68 / $102.68
| Facility | | $102.68 | $102.68 | $102.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.92 / $100.86 / $122.74
| Professional | | $62.92 | $100.86 | $122.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.59 / $30.41 / $111.38
| Professional | | $22.59 | $30.41 | $111.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.40 / $83.40 / $137.59
| Professional | | $83.40 | $83.40 | $137.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.81 / $27.10 / $33.54
| Professional | | $25.81 | $27.10 | $33.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.68 / $121.74 / $210.90
| Professional | | $56.68 | $121.74 | $210.90 |