- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.41 / $164.42 / $164.42
| Professional | | $29.41 | $164.42 | $164.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.36 / $75.56 / $145.75
| Facility | | $38.36 | $75.56 | $145.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.44 / $29.32 / $36.65
| Professional | | $13.44 | $29.32 | $36.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.51 / $49.86 / $75.56
| Facility | | $28.51 | $49.86 | $75.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.01 / $23.01 / $30.68
| Professional | | $23.01 | $23.01 | $30.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.74 / $10.74 / $26.97
| Professional | | $10.74 | $10.74 | $26.97 |