- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.20 / $170.20 / $170.20
| Facility | | $170.20 | $170.20 | $170.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.02 / $24.27 / $24.34
| Professional | | $23.02 | $24.27 | $24.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.37 / $34.86 / $36.40
| Facility | | $31.37 | $34.86 | $36.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.22 / $39.22 / $39.22
| Professional | | $39.22 | $39.22 | $39.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.30 / $87.30 / $87.30
| Facility | | $87.30 | $87.30 | $87.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.23 / $19.23 / $19.23
| Professional | | $19.23 | $19.23 | $19.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.81 / $17.76 / $47.36
| Professional | | $13.81 | $17.76 | $47.36 |