- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.30 / $40.00 / $51.84
| Professional | | $22.30 | $40.00 | $51.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.60 / $52.60 / $52.60
| Facility | | $52.60 | $52.60 | $52.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.60 / $52.60 / $52.60
| Professional | | $52.60 | $52.60 | $52.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.42 / $44.42 / $65.08
| Facility | | $44.42 | $44.42 | $65.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.76 / $44.42 / $52.54
| Professional | | $37.76 | $44.42 | $52.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.28 / $33.02 / $64.80
| Professional | | $19.28 | $33.02 | $64.80 |