- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.72 / $107.78 / $107.78
| Professional | | $14.72 | $107.78 | $107.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.38 / $40.67 / $40.67
| Facility | | $21.38 | $40.67 | $40.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $40.67 / $40.67
| Professional | | $21.38 | $40.67 | $40.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.07 / $38.72 / $40.67
| Facility | | $19.07 | $38.72 | $40.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $30.52 / $40.69
| Professional | | $21.38 | $30.52 | $40.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.43 / $17.05 / $19.54
| Professional | | $15.43 | $17.05 | $19.54 |