- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $64.57 / $123.03
| Professional | | $52.48 | $64.57 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.44 / $23.44 / $23.44
| Professional | | $23.44 | $23.44 | $23.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.72 / $3.72 / $7.24
| Facility | | $3.72 | $3.72 | $7.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.72 / $4.79 / $10.47
| Professional | | $3.72 | $4.79 | $10.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.90 / $5.01 / $32.36
| Professional | | $4.90 | $5.01 | $32.36 |