- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.30 / $20.30 / $104.66
| Professional | | $20.30 | $20.30 | $104.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.27 / $107.08 / $178.43
| Facility | | $27.27 | $107.08 | $178.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.74 / $33.08 / $65.95
| Professional | | $22.74 | $33.08 | $65.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.60 / $21.60 / $21.60
| Professional | | $21.60 | $21.60 | $21.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.35 / $45.34 / $169.74
| Facility | | $21.35 | $45.34 | $169.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.76 / $27.58 / $45.37
| Professional | | $23.76 | $27.58 | $45.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.87 / $27.58 / $45.37
| Professional | | $23.87 | $27.58 | $45.37 |