- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $186.21
| Facility | | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.50 / $6.46 / $7.41
| Professional | | $5.50 | $6.46 | $7.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $16.98 / $21.38
| Professional | | $16.98 | $16.98 | $21.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $16.22 / $19.95
| Professional | | $16.22 | $16.22 | $19.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $186.21
| Facility | | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $16.22 / $67.61
| Professional | | $16.22 | $16.22 | $67.61 |