- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.57 / $170.91 / $170.91
| Professional | | $30.57 | $170.91 | $170.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.54 / $51.83 / $78.54
| Facility | | $38.54 | $51.83 | $78.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.20 / $38.20 / $38.54
| Professional | | $18.20 | $38.20 | $38.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.54 / $45.19 / $78.54
| Facility | | $38.54 | $45.19 | $78.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.92 / $23.92 / $38.54
| Professional | | $23.92 | $23.92 | $38.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.16 / $11.16 / $36.53
| Professional | | $11.16 | $11.16 | $36.53 |