- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.08 / $107.00 / $134.63
| Professional | | $24.08 | $107.00 | $134.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.36 / $40.83 / $61.88
| Facility | | $30.36 | $40.83 | $61.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.93 / $30.36 / $30.46
| Professional | | $12.93 | $30.36 | $30.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.36 / $35.60 / $61.88
| Facility | | $27.36 | $35.60 | $61.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.85 / $18.85 / $30.36
| Professional | | $18.85 | $18.85 | $30.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.78 / $8.78 / $25.89
| Professional | | $8.78 | $8.78 | $25.89 |