- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.46 / $86.42 / $86.42
| Professional | | $15.46 | $86.42 | $86.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.48 / $26.21 / $39.72
| Facility | | $19.48 | $26.21 | $39.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.19 / $19.48 / $19.62
| Professional | | $9.19 | $19.48 | $19.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.48 / $22.85 / $39.72
| Facility | | $19.48 | $22.85 | $39.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.10 / $12.10 / $19.48
| Professional | | $12.10 | $12.10 | $19.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.64 / $5.64 / $18.47
| Professional | | $5.64 | $5.64 | $18.47 |