- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.00 / $26.00 / $26.00
| Professional | | $26.00 | $26.00 | $26.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.87 / $33.08 / $65.62
| Facility | | $22.87 | $33.08 | $65.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.28 / $5.04 / $31.03
| Professional | | $4.28 | $5.04 | $31.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.38 / $90.00 / $109.64
| Facility | | $75.38 | $90.00 | $109.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.52 / $20.65 / $27.73
| Professional | | $16.52 | $20.65 | $27.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.09 / $30.09 / $32.02
| Professional | | $30.09 | $30.09 | $32.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.35 / $6.35 / $11.89
| Facility | | $6.35 | $6.35 | $11.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.13 / $17.23 / $48.84
| Professional | | $11.13 | $17.23 | $48.84 |