- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.42 / $52.42 / $52.42
| Professional | | $52.42 | $52.42 | $52.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.63 / $6.63 / $7.30
| Facility | | $6.63 | $6.63 | $7.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.51 / $18.51 / $22.10
| Professional | | $18.51 | $18.51 | $22.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.50 / $43.50 / $43.50
| Professional | | $43.50 | $43.50 | $43.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.42 / $100.00 / $100.00
| Facility | | $52.42 | $100.00 | $100.00 |