- 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
- $11.63 / $17.04 / $106.08
| Professional | | $11.63 | $17.04 | $106.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.25 / $10.25 / $137.59
| Professional | | $10.25 | $10.25 | $137.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.12 / $11.68 / $14.46
| Professional | | $11.12 | $11.68 | $14.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.38 / $121.97 / $210.90
| Professional | | $24.38 | $121.97 | $210.90 |