- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.50 / $45.04 / $56.30
| Professional | | $28.50 | $45.04 | $56.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.86 / $35.86 / $113.00
| Facility | | $35.86 | $35.86 | $113.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.00 / $46.00 / $46.00
| Professional | | $46.00 | $46.00 | $46.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.12 / $22.12 / $22.12
| Facility | | $22.12 | $22.12 | $22.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.09 / $42.00 / $52.95
| Professional | | $33.09 | $42.00 | $52.95 |