- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.46 / $10.58 / $15.87
| Facility | | $8.46 | $10.58 | $15.87 |
- 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
- $162.06 / $162.06 / $162.06
| Facility | | $162.06 | $162.06 | $162.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.47 / $81.01 / $242.55
| Facility | | $37.47 | $81.01 | $242.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.44 / $204.44 / $255.54
| Professional | | $204.44 | $204.44 | $255.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.26 / $130.26 / $130.26
| Facility | | $130.26 | $130.26 | $130.26 |