- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.83 / $174.26 / $192.96
| Facility | | $93.83 | $174.26 | $192.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.26 / $182.64 / $182.86
| Professional | | $174.26 | $182.64 | $182.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.25 / $5.30 / $6.67
| Professional | | $5.25 | $5.30 | $6.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.26 / $174.26 / $183.77
| Facility | | $174.26 | $174.26 | $183.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.40 / $111.40 / $151.80
| Professional | | $111.40 | $111.40 | $151.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.40 / $111.40 / $111.40
| Professional | | $111.40 | $111.40 | $111.40 |