- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.04 / $52.04 / $81.36
| Professional | | $52.04 | $52.04 | $81.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.74 / $90.74 / $90.74
| Facility | | $90.74 | $90.74 | $90.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.74 / $90.74 / $90.74
| Professional | | $90.74 | $90.74 | $90.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.32 / $51.32 / $100.64
| Facility | | $51.32 | $51.32 | $100.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.46 / $37.46 / $51.32
| Professional | | $37.46 | $37.46 | $51.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.04 / $40.98 / $45.49
| Professional | | $37.04 | $40.98 | $45.49 |