- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.46 / $8.46 / $10.58
| Facility | | $8.46 | $8.46 | $10.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $10.58 / $20.00
| Professional | | $10.58 | $10.58 | $20.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.00 / $117.71 / $158.36
| Facility | | $97.00 | $117.71 | $158.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.50 / $180.50 / $230.77
| Professional | | $180.50 | $180.50 | $230.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.76 / $132.22 / $340.36
| Facility | | $39.76 | $132.22 | $340.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.44 / $204.44 / $255.54
| Professional | | $204.44 | $204.44 | $255.54 |