- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.60 / $118.32 / $122.07
| Facility | | $98.60 | $118.32 | $122.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.25 / $32.25 / $40.31
| Professional | | $32.25 | $32.25 | $40.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.22 / $32.22 / $32.22
| Facility | | $32.22 | $32.22 | $32.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.22 / $32.22 / $54.00
| Professional | | $32.22 | $32.22 | $54.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $90.00 / $90.00
| Facility | | $90.00 | $90.00 | $90.00 |