- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.20 / $32.01 / $147.86
| Professional | | $26.20 | $32.01 | $147.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.70 / $37.70 / $37.70
| Facility | | $37.70 | $37.70 | $37.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.70 / $37.70 / $37.70
| Professional | | $37.70 | $37.70 | $37.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.33 / $33.33 / $50.52
| Facility | | $33.33 | $33.33 | $50.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.33 / $33.33 / $43.75
| Professional | | $28.33 | $33.33 | $43.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.05 / $26.05 / $60.20
| Professional | | $16.05 | $26.05 | $60.20 |