- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.92 / $105.92 / $105.92
| Facility | | $105.92 | $105.92 | $105.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.48 / $105.92 / $122.74
| Professional | | $79.48 | $105.92 | $122.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.16 / $11.47 / $14.56
| Professional | | $11.16 | $11.47 | $14.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.25 / $10.25 / $10.25
| Professional | | $10.25 | $10.25 | $10.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.58 / $12.78 / $19.89
| Professional | | $9.58 | $12.78 | $19.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.51 / $105.92 / $122.74
| Professional | | $94.51 | $105.92 | $122.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.79 / $149.31 / $180.20
| Professional | | $87.79 | $149.31 | $180.20 |