- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.22 / $158.22 / $158.22
| Facility | | $158.22 | $158.22 | $158.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.17 / $37.17 / $46.46
| Professional | | $37.17 | $37.17 | $46.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.52 / $9.52 / $116.21
| Facility | | $9.52 | $9.52 | $116.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.62 / $12.62 / $12.62
| Professional | | $12.62 | $12.62 | $12.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.10 / $12.55 / $25.90
| Professional | | $8.10 | $12.55 | $25.90 |