- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.09 / $84.36 / $84.36
| Professional | | $15.09 | $84.36 | $84.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.02 / $25.58 / $38.77
| Facility | | $19.02 | $25.58 | $38.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.02 / $19.02 / $19.10
| Professional | | $9.02 | $19.02 | $19.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.02 / $22.30 / $38.77
| Facility | | $19.02 | $22.30 | $38.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.81 / $13.12 / $19.02
| Professional | | $11.81 | $13.12 | $19.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.51 / $5.67 / $18.03
| Professional | | $5.51 | $5.67 | $18.03 |