- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.61 / $20.61 / $176.76
| Professional | | $20.61 | $20.61 | $176.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.36 / $40.36 / $40.36
| Facility | | $40.36 | $40.36 | $40.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.31 / $40.36 / $71.63
| Professional | | $34.31 | $40.36 | $71.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.63 / $30.56 / $45.80
| Professional | | $4.63 | $30.56 | $45.80 |