- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.61 / $137.61 / $137.61
| Facility | | $137.61 | $137.61 | $137.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.73 / $29.70 / $40.39
| Professional | | $26.73 | $29.70 | $40.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.01 / $27.86 / $43.37
| Professional | | $11.01 | $27.86 | $43.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.80 / $33.28 / $38.70
| Professional | | $25.80 | $33.28 | $38.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.77 / $13.24 / $24.18
| Professional | | $10.77 | $13.24 | $24.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.94 / $7.94 / $10.18
| Professional | | $7.94 | $7.94 | $10.18 |