- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $107.15
| Professional | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.42 / $28.18 / $48.98
| Facility | | $20.42 | $28.18 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.94 / $14.45 / $26.92
| Professional | | $7.94 | $14.45 | $26.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $97.72 / $120.23
| Facility | | $83.18 | $97.72 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.78 / $25.12 / $27.54
| Professional | | $17.78 | $25.12 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $33.11
| Professional | | $30.20 | $30.20 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.22 / $17.78 / $48.98
| Professional | | $11.22 | $17.78 | $48.98 |