- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.04 / $235.08 / $235.08
| Professional | | $42.04 | $235.08 | $235.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.01 / $71.29 / $108.03
| Facility | | $53.01 | $71.29 | $108.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.79 / $52.66 / $53.01
| Professional | | $38.79 | $52.66 | $53.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.01 / $82.04 / $108.03
| Facility | | $53.01 | $82.04 | $108.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.90 / $36.56 / $53.01
| Professional | | $32.90 | $36.56 | $53.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.36 / $15.36 / $62.60
| Professional | | $15.36 | $15.36 | $62.60 |