- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.86 / $138.13 / $138.13
| Professional | | $18.86 | $138.13 | $138.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.38 / $52.01 / $52.01
| Facility | | $27.38 | $52.01 | $52.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.38 / $52.01 / $52.01
| Professional | | $27.38 | $52.01 | $52.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.43 / $49.53 / $52.01
| Facility | | $24.43 | $49.53 | $52.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.03 / $39.90 / $52.04
| Professional | | $39.03 | $39.90 | $52.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.76 / $21.86 / $36.43
| Professional | | $19.76 | $21.86 | $36.43 |