- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.12 / $72.44 / $141.25
| Facility | | $50.12 | $72.44 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $87.10 / $107.15
| Professional | | $74.13 | $87.10 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.72 / $4.27 / $7.94
| Professional | | $3.72 | $4.27 | $7.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $87.10 / $87.10
| Professional | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.12 / $72.44 / $100.00
| Facility | | $50.12 | $72.44 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $87.10 / $117.49
| Professional | | $74.13 | $87.10 | $117.49 |