- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.22 / $103.22 / $121.43
| Facility | | $103.22 | $103.22 | $121.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.79 / $103.22 / $103.22
| Professional | | $100.79 | $103.22 | $103.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.38 / $12.38 / $18.57
| Facility | | $12.38 | $12.38 | $18.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.22 / $103.22 / $103.22
| Facility | | $103.22 | $103.22 | $103.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.82 / $11.82 / $150.44
| Professional | | $11.82 | $11.82 | $150.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.15 / $101.19 / $121.43
| Professional | | $98.15 | $101.19 | $121.43 |