- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.31 / $36.31 / $36.31
| Professional | | $36.31 | $36.31 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $60.26 / $60.26
| Professional | | $44.67 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $85.11 / $3,467.37
| Professional | | $60.26 | $85.11 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.31 / $36.31 / $57.54
| Facility | | $36.31 | $36.31 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $12.88 / $41.69
| Professional | | $12.02 | $12.88 | $41.69 |