- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.55 / $100.55 / $111.39
| Facility | | $100.55 | $100.55 | $111.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.94 / $95.13 / $169.27
| Professional | | $75.94 | $95.13 | $169.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.00 / $112.00 / $112.00
| Professional | | $112.00 | $112.00 | $112.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.59 / $107.55 / $139.24
| Professional | | $75.59 | $107.55 | $139.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.27 / $105.35 / $174.97
| Professional | | $83.27 | $105.35 | $174.97 |