- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.57 / $125.28 / $155.52
| Facility | | $37.57 | $125.28 | $155.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.58 / $134.00 / $232.54
| Professional | | $37.58 | $134.00 | $232.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.71 / $110.71 / $110.71
| Facility | | $110.71 | $110.71 | $110.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.26 / $16.26 / $16.43
| Professional | | $16.26 | $16.26 | $16.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.50 / $43.50 / $43.50
| Professional | | $43.50 | $43.50 | $43.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.42 / $43.70 / $64.23
| Professional | | $36.42 | $43.70 | $64.23 |