- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.34 / $113.75 / $113.75
| Professional | | $20.34 | $113.75 | $113.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.65 / $34.50 / $52.27
| Facility | | $25.65 | $34.50 | $52.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.08 / $25.65 / $25.81
| Professional | | $12.08 | $25.65 | $25.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.65 / $30.07 / $52.27
| Facility | | $25.65 | $30.07 | $52.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.92 / $17.69 / $25.65
| Professional | | $15.92 | $17.69 | $25.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.43 / $7.64 / $24.32
| Professional | | $7.43 | $7.64 | $24.32 |