- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.18 / $174.32 / $174.32
| Professional | | $31.18 | $174.32 | $174.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.31 / $52.86 / $80.11
| Facility | | $39.31 | $52.86 | $80.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.74 / $39.24 / $39.31
| Professional | | $11.74 | $39.24 | $39.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.31 / $52.86 / $80.11
| Facility | | $39.31 | $52.86 | $80.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.40 / $24.40 / $39.31
| Professional | | $24.40 | $24.40 | $39.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.32 / $11.39 / $27.11
| Professional | | $10.32 | $11.39 | $27.11 |