- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.64 / $18.64 / $18.64
| Professional | | $18.64 | $18.64 | $18.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $82.86 / $182.29 / $341.71
| Facility | | $82.86 | $182.29 | $341.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.83 / $20.83 / $20.83
| Professional | | $20.83 | $20.83 | $20.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.83 / $32.83 / $359.90
| Facility | | $32.83 | $32.83 | $359.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.66 / $22.72 / $28.39
| Professional | | $11.66 | $22.72 | $28.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.83 / $32.83 / $359.90
| Facility | | $32.83 | $32.83 | $359.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.66 / $22.72 / $28.39
| Professional | | $11.66 | $22.72 | $28.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.96 / $11.77 / $110.25
| Professional | | $8.96 | $11.77 | $110.25 |