- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.44 / $114.26 / $114.26
| Professional | | $20.44 | $114.26 | $114.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.77 / $34.65 / $52.51
| Facility | | $25.77 | $34.65 | $52.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.38 / $25.77 / $25.81
| Professional | | $10.38 | $25.77 | $25.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.87 / $30.21 / $52.51
| Facility | | $19.87 | $30.21 | $52.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.99 / $15.99 / $25.77
| Professional | | $15.99 | $15.99 | $25.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.46 / $8.61 / $20.72
| Professional | | $7.46 | $8.61 | $20.72 |