- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.83 / $137.29 / $160.02
| Facility | | $109.83 | $137.29 | $160.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.20 / $7.20 / $17.00
| Professional | | $7.20 | $7.20 | $17.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.44 / $20.52 / $33.65
| Facility | | $17.44 | $20.52 | $33.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $21.33 / $36.01
| Professional | | $20.00 | $21.33 | $36.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.80 / $16.80 / $20.34
| Professional | | $16.80 | $16.80 | $20.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.01 / $22.24 / $30.03
| Professional | | $12.01 | $22.24 | $30.03 |