- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.12 / $84.55 / $84.55
| Professional | | $15.12 | $84.55 | $84.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.07 / $25.64 / $38.86
| Facility | | $19.07 | $25.64 | $38.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.27 / $19.07 / $19.10
| Professional | | $5.27 | $19.07 | $19.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.23 / $22.36 / $38.86
| Facility | | $11.23 | $22.36 | $38.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.84 / $11.84 / $19.07
| Professional | | $11.84 | $11.84 | $19.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.42 / $5.52 / $13.15
| Professional | | $4.42 | $5.52 | $13.15 |