- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.89 / $40.74 / $75.86
| Professional | | $20.89 | $40.74 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.62 / $41.69 / $52.48
| Facility | | $31.62 | $41.69 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $66.07 / $100.00
| Professional | | $42.66 | $66.07 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $56.23
| Facility | | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $63.10 / $213.80
| Professional | | $34.67 | $63.10 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.30 / $35.48 / $87.10
| Professional | | $26.30 | $35.48 | $87.10 |