- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.25 / $33.60 / $187.89
| Professional | | $24.25 | $33.60 | $187.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.37 / $49.67 / $166.55
| Facility | | $42.37 | $49.67 | $166.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.29 / $42.37 / $42.37
| Professional | | $14.29 | $42.37 | $42.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.37 / $49.67 / $166.55
| Facility | | $42.37 | $49.67 | $166.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.30 / $26.30 / $42.37
| Professional | | $26.30 | $26.30 | $42.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.88 / $12.27 / $29.22
| Professional | | $11.88 | $12.27 | $29.22 |