- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $87.10 / $177.83
| Professional | | $57.54 | $87.10 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.18 / $22.39 / $89.13
| Professional | | $13.18 | $22.39 | $89.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.46 / $6.46 / $12.59
| Facility | | $6.46 | $6.46 | $12.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.46 / $6.46 / $12.59
| Professional | | $6.46 | $6.46 | $12.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $8.51 / $21.38
| Professional | | $5.01 | $8.51 | $21.38 |