- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.57 / $81.47 / $81.47
| Professional | | $14.57 | $81.47 | $81.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.37 / $24.71 / $37.44
| Facility | | $18.37 | $24.71 | $37.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.68 / $18.07 / $18.37
| Professional | | $8.68 | $18.07 | $18.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.37 / $21.54 / $37.44
| Facility | | $18.37 | $21.54 | $37.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.40 / $12.67 / $18.37
| Professional | | $11.40 | $12.67 | $18.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.32 / $5.32 / $17.42
| Professional | | $5.32 | $5.32 | $17.42 |