- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.75 / $104.81 / $104.81
| Professional | | $18.75 | $104.81 | $104.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.64 / $31.79 / $48.17
| Facility | | $23.64 | $31.79 | $48.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.54 / $23.23 / $23.64
| Professional | | $2.54 | $23.23 | $23.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.25 / $27.71 / $48.17
| Facility | | $5.25 | $27.71 | $48.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.67 / $14.67 / $23.64
| Professional | | $14.67 | $14.67 | $23.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.06 / $6.85 / $16.30
| Professional | | $2.06 | $6.85 | $16.30 |