- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.51 / $32.25 / $32.25
| Professional | | $26.51 | $32.25 | $32.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.63 / $39.01 / $49.05
| Professional | | $38.63 | $39.01 | $49.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.88 / $26.51 / $44.82
| Facility | | $19.88 | $26.51 | $44.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.04 / $45.25 / $207.28
| Professional | | $24.04 | $45.25 | $207.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.04 / $42.14 / $61.46
| Professional | | $24.04 | $42.14 | $61.46 |