- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $10.47 / $10.47
| Professional | | $10.47 | $10.47 | $10.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.43 / $101.47 / $106.64
| Facility | | $46.43 | $101.47 | $106.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.56 / $23.56 / $23.56
| Facility | | $23.56 | $23.56 | $23.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.12 / $9.38 / $20.13
| Professional | | $4.12 | $9.38 | $20.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.56 / $23.56 / $23.56
| Facility | | $23.56 | $23.56 | $23.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.12 / $9.38 / $20.13
| Professional | | $4.12 | $9.38 | $20.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $8.44 / $16.26
| Professional | | $5.01 | $8.44 | $16.26 |