- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.86 / $111.05 / $111.05
| Professional | | $19.86 | $111.05 | $111.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.04 / $33.68 / $51.03
| Facility | | $25.04 | $33.68 | $51.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.14 / $24.78 / $25.04
| Professional | | $7.14 | $24.78 | $25.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.14 / $29.36 / $51.03
| Facility | | $15.14 | $29.36 | $51.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.54 / $15.54 / $25.04
| Professional | | $15.54 | $15.54 | $25.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.96 / $7.25 / $17.27
| Professional | | $5.96 | $7.25 | $17.27 |