- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.02 / $11.02 / $11.02
| Professional | | $11.02 | $11.02 | $11.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.75 / $33.19 / $75.22
| Facility | | $27.75 | $33.19 | $75.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.11 / $283.32 / $283.32
| Professional | | $32.11 | $283.32 | $283.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.56 / $36.22 / $45.36
| Facility | | $33.56 | $36.22 | $45.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.04 / $32.11 / $36.22
| Professional | | $24.04 | $32.11 | $36.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.10 / $47.10 / $47.10
| Professional | | $47.10 | $47.10 | $47.10 |