- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.51 / $173.51 / $173.51
| Facility | | $173.51 | $173.51 | $173.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.05 / $6.05 / $33.68
| Professional | | $6.05 | $6.05 | $33.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.52 / $20.65 / $30.19
| Professional | | $16.52 | $20.65 | $30.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.25 / $15.25 / $18.47
| Professional | | $15.25 | $15.25 | $18.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.51 / $173.51 / $173.51
| Facility | | $173.51 | $173.51 | $173.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.20 / $13.61 / $32.89
| Professional | | $13.20 | $13.61 | $32.89 |