- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.76 / $57.76 / $101.15
| Professional | | $57.76 | $57.76 | $101.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.81 / $112.81 / $112.81
| Facility | | $112.81 | $112.81 | $112.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.81 / $112.81 / $112.81
| Professional | | $112.81 | $112.81 | $112.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.22 / $66.22 / $148.50
| Facility | | $66.22 | $66.22 | $148.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.34 / $48.34 / $66.22
| Professional | | $48.34 | $48.34 | $66.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.65 / $67.34 / $77.83
| Professional | | $45.65 | $67.34 | $77.83 |