- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.29 / $102.24 / $102.24
| Professional | | $18.29 | $102.24 | $102.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.06 / $31.01 / $46.98
| Facility | | $23.06 | $31.01 | $46.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.21 / $22.72 / $23.06
| Professional | | $10.21 | $22.72 | $23.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.66 / $27.03 / $46.98
| Facility | | $21.66 | $27.03 | $46.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.31 / $14.90 / $23.06
| Professional | | $14.31 | $14.90 | $23.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.68 / $6.68 / $20.49
| Professional | | $6.68 | $6.68 | $20.49 |