- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.43 / $39.78 / $56.71
| Professional | | $31.43 | $39.78 | $56.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.63 / $139.63 / $139.63
| Facility | | $139.63 | $139.63 | $139.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.38 / $140.99 / $140.99
| Professional | | $95.38 | $140.99 | $140.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.75 / $29.83 / $36.00
| Facility | | $23.75 | $29.83 | $36.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.17 / $33.08 / $40.51
| Professional | | $27.17 | $33.08 | $40.51 |