- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.65 / $87.51 / $87.51
| Professional | | $15.65 | $87.51 | $87.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.73 / $26.54 / $40.22
| Facility | | $19.73 | $26.54 | $40.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.83 / $19.62 / $19.73
| Professional | | $7.83 | $19.62 | $19.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.55 / $23.14 / $40.22
| Facility | | $16.55 | $23.14 | $40.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.25 / $12.25 / $19.73
| Professional | | $12.25 | $12.25 | $19.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.72 / $5.72 / $15.65
| Professional | | $5.72 | $5.72 | $15.65 |