- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.87 / $233.93 / $233.93
| Facility | | $109.87 | $233.93 | $233.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.88 / $109.88 / $188.85
| Professional | | $109.88 | $109.88 | $188.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.31 / $40.44 / $40.44
| Professional | | $26.31 | $40.44 | $40.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.70 / $36.70 / $36.70
| Professional | | $36.70 | $36.70 | $36.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.88 / $109.88 / $203.20
| Professional | | $109.88 | $109.88 | $203.20 |