- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.78 / $183.26 / $183.26
| Professional | | $32.78 | $183.26 | $183.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.33 / $55.58 / $84.22
| Facility | | $41.33 | $55.58 | $84.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.03 / $40.78 / $41.33
| Professional | | $18.03 | $40.78 | $41.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.22 / $48.45 / $84.22
| Facility | | $38.22 | $48.45 | $84.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.65 / $25.65 / $41.33
| Professional | | $25.65 | $25.65 | $41.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.97 / $11.97 / $36.15
| Professional | | $11.97 | $11.97 | $36.15 |