- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $57.54 / $72.44
| Professional | | $21.38 | $57.54 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $52.48 / $194.98
| Facility | | $39.81 | $52.48 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $50.12 / $72.44
| Professional | | $34.67 | $50.12 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $66.07 / $66.07
| Professional | | $66.07 | $66.07 | $66.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |