- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.57 / $18.64 / $18.64
| Professional | | $18.57 | $18.64 | $18.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $82.86 / $190.92 / $261.32
| Facility | | $82.86 | $190.92 | $261.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.43 / $17.43 / $17.43
| Professional | | $17.43 | $17.43 | $17.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.64 / $23.64 / $275.20
| Facility | | $23.64 | $23.64 | $275.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $16.52 / $22.42
| Professional | | $9.77 | $16.52 | $22.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.64 / $23.64 / $275.20
| Facility | | $23.64 | $23.64 | $275.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $16.52 / $22.42
| Professional | | $9.77 | $16.52 | $22.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.17 / $8.96 / $20.92
| Professional | | $6.17 | $8.96 | $20.92 |