- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.26 / $107.70 / $107.70
| Professional | | $19.26 | $107.70 | $107.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.29 / $32.65 / $49.50
| Facility | | $24.29 | $32.65 | $49.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.57 / $24.26 / $24.29
| Professional | | $11.57 | $24.26 | $24.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.29 / $28.48 / $49.50
| Facility | | $24.29 | $28.48 | $49.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.08 / $15.08 / $24.29
| Professional | | $15.08 | $15.08 | $24.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.04 / $7.04 / $23.03
| Professional | | $7.04 | $7.04 | $23.03 |