- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.22 / $124.23 / $124.23
| Professional | | $22.22 | $124.23 | $124.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.01 / $37.67 / $57.09
| Facility | | $28.01 | $37.67 | $57.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.93 / $27.88 / $28.01
| Professional | | $12.93 | $27.88 | $28.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.73 / $32.84 / $57.09
| Facility | | $23.73 | $32.84 | $57.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.39 / $17.39 / $28.01
| Professional | | $17.39 | $17.39 | $28.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.11 / $8.11 / $26.00
| Professional | | $8.11 | $8.11 | $26.00 |