- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.27 / $191.61 / $191.61
| Professional | | $34.27 | $191.61 | $191.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.21 / $50.66 / $169.86
| Facility | | $43.21 | $50.66 | $169.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.78 / $43.21 / $43.21
| Professional | | $13.78 | $43.21 | $43.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.21 / $50.66 / $169.86
| Facility | | $43.21 | $50.66 | $169.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.82 / $26.82 / $43.21
| Professional | | $26.82 | $26.82 | $43.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.47 / $12.52 / $29.80
| Professional | | $11.47 | $12.52 | $29.80 |