- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.12 / $81.12 / $136.55
| Facility | | $81.12 | $81.12 | $136.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.59 / $89.12 / $136.55
| Professional | | $70.59 | $89.12 | $136.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.08 / $40.08 / $40.08
| Professional | | $40.08 | $40.08 | $40.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.78 / $58.61 / $80.25
| Professional | | $37.78 | $58.61 | $80.25 |
- 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
- $34.04 / $51.83 / $87.21
| Professional | | $34.04 | $51.83 | $87.21 |