- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.10 / $50.10 / $136.41
| Professional | | $50.10 | $50.10 | $136.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.41 / $163.41 / $202.49
| Facility | | $163.41 | $163.41 | $202.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.07 / $52.07 / $54.03
| Professional | | $52.07 | $52.07 | $54.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.07 / $52.07 / $56.05
| Professional | | $52.07 | $52.07 | $56.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.99 / $62.48 / $136.16
| Professional | | $55.99 | $62.48 | $136.16 |