- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.62 / $48.62 / $48.62
| Professional | | $48.62 | $48.62 | $48.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.97 / $302.57 / $495.34
| Facility | | $215.97 | $302.57 | $495.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.69 / $34.69 / $43.37
| Professional | | $34.69 | $34.69 | $43.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.35 / $34.69 / $43.37
| Professional | | $22.35 | $34.69 | $43.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.10 / $23.35 / $54.49
| Professional | | $18.10 | $23.35 | $54.49 |