- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.14 / $24.71 / $38.06
| Professional | | $12.14 | $24.71 | $38.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.84 / $126.84 / $127.73
| Facility | | $126.84 | $126.84 | $127.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.33 / $35.86 / $94.56
| Professional | | $15.33 | $35.86 | $94.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.22 / $40.33 / $94.56
| Professional | | $20.22 | $40.33 | $94.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.94 / $46.59 / $135.44
| Professional | | $34.94 | $46.59 | $135.44 |