- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $114.82 / $177.83
| Professional | | $87.10 | $114.82 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.72 / $10.72 / $10.72
| Facility | | $10.72 | $10.72 | $10.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.23 / $10.72 / $10.72
| Professional | | $10.23 | $10.72 | $10.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $15.85 / $19.50
| Professional | | $15.85 | $15.85 | $19.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.45 / $38.02 / $42.66
| Facility | | $14.45 | $38.02 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.45 / $15.85 / $20.42
| Professional | | $14.45 | $15.85 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $15.85 / $15.85
| Professional | | $15.85 | $15.85 | $15.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.78 / $17.78 / $17.78
| Facility | | $17.78 | $17.78 | $17.78 |