- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.32 / $56.32 / $56.32
| Facility | | $56.32 | $56.32 | $56.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.65 / $33.77 / $61.21
| Professional | | $20.65 | $33.77 | $61.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.29 / $193.18 / $208.70
| Facility | | $36.29 | $193.18 | $208.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.48 / $48.96 / $127.28
| Professional | | $25.48 | $48.96 | $127.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.95 / $61.81 / $127.28
| Professional | | $33.95 | $61.81 | $127.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.30 / $64.40 / $187.22
| Professional | | $48.30 | $64.40 | $187.22 |