- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.79 / $33.86 / $44.00
| Professional | | $28.79 | $33.86 | $44.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.02 / $21.02 / $23.13
| Facility | | $21.02 | $21.02 | $23.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.61 / $17.61 / $21.02
| Professional | | $17.61 | $17.61 | $21.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.56 / $33.86 / $44.02
| Facility | | $26.56 | $33.86 | $44.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.50 / $24.43 / $207.28
| Professional | | $18.50 | $24.43 | $207.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.50 / $24.00 / $38.54
| Professional | | $18.50 | $24.00 | $38.54 |