- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.66 / $22.84 / $48.00
| Professional | | $17.66 | $22.84 | $48.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.48 / $45.08 / $81.51
| Facility | | $12.48 | $45.08 | $81.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.20 / $41.60 / $56.68
| Professional | | $31.20 | $41.60 | $56.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.50 / $19.50 / $151.94
| Professional | | $19.50 | $19.50 | $151.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.66 / $22.84 / $90.90
| Facility | | $17.66 | $22.84 | $90.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.65 / $42.65 / $56.12
| Professional | | $42.65 | $42.65 | $56.12 |