- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.30 / $61.30 / $78.59
| Facility | | $61.30 | $61.30 | $78.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.75 / $74.66 / $82.72
| Professional | | $64.75 | $74.66 | $82.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.45 / $105.35 / $105.35
| Facility | | $101.45 | $105.35 | $105.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.67 / $102.67 / $102.67
| Professional | | $102.67 | $102.67 | $102.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.43 / $80.45 / $108.06
| Professional | | $72.43 | $80.45 | $108.06 |