- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.20 / $127.30 / $127.30
| Facility | | $110.20 | $127.30 | $127.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.20 / $110.20 / $110.20
| Professional | | $110.20 | $110.20 | $110.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.30 / $191.71 / $419.56
| Professional | | $42.30 | $191.71 | $419.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.48 / $88.10 / $100.68
| Facility | | $81.48 | $88.10 | $100.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.73 / $105.73 / $132.16
| Professional | | $105.73 | $105.73 | $132.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.85 / $21.85 / $21.85
| Facility | | $21.85 | $21.85 | $21.85 |