- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.03 / $112.78 / $112.78
| Professional | | $22.03 | $112.78 | $112.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.30 / $46.05 / $46.05
| Facility | | $27.30 | $46.05 | $46.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.30 / $46.05 / $46.05
| Professional | | $27.30 | $46.05 | $46.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.61 / $38.46 / $55.31
| Facility | | $14.61 | $38.46 | $55.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.30 / $46.05 / $46.05
| Professional | | $27.30 | $46.05 | $46.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.63 / $18.50 / $21.35
| Professional | | $17.63 | $18.50 | $21.35 |