- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.29 / $105.73 / $124.39
| Facility | | $93.29 | $105.73 | $124.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.17 / $93.29 / $129.47
| Professional | | $17.17 | $93.29 | $129.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.43 / $80.43 / $107.54
| Professional | | $80.43 | $80.43 | $107.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.94 / $138.94 / $291.45
| Professional | | $138.94 | $138.94 | $291.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.55 / $121.13 / $287.19
| Professional | | $60.55 | $121.13 | $287.19 |