- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.28 / $54.18 / $67.73
| Professional | | $34.28 | $54.18 | $67.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.75 / $195.75 / $195.75
| Facility | | $195.75 | $195.75 | $195.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.00 / $57.00 / $57.00
| Professional | | $57.00 | $57.00 | $57.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.63 / $40.60 / $65.56
| Facility | | $19.63 | $40.60 | $65.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.09 / $42.88 / $60.20
| Professional | | $29.09 | $42.88 | $60.20 |