- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.44 / $142.34 / $142.34
| Professional | | $19.44 | $142.34 | $142.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.84 / $53.64 / $53.64
| Facility | | $33.84 | $53.64 | $53.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.84 / $53.64 / $53.64
| Professional | | $33.84 | $53.64 | $53.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.18 / $51.09 / $53.64
| Facility | | $25.18 | $51.09 | $53.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.84 / $40.27 / $53.69
| Professional | | $33.84 | $40.27 | $53.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.36 / $22.53 / $34.47
| Professional | | $20.36 | $22.53 | $34.47 |