- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.48 / $131.30 / $131.30
| Professional | | $23.48 | $131.30 | $131.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.61 / $39.82 / $60.34
| Facility | | $29.61 | $39.82 | $60.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.95 / $29.43 / $29.61
| Professional | | $13.95 | $29.43 | $29.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.61 / $34.71 / $60.34
| Facility | | $29.61 | $34.71 | $60.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.38 / $20.42 / $29.61
| Professional | | $18.38 | $20.42 | $29.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.42 / $20.42 / $20.42
| Facility | | $20.42 | $20.42 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.58 / $8.58 / $20.42
| Professional | | $8.58 | $8.58 | $20.42 |