- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.48 / $10.48 / $10.48
| Professional | | $10.48 | $10.48 | $10.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.56 / $101.47 / $106.64
| Facility | | $46.56 | $101.47 | $106.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.07 / $10.07 / $10.07
| Facility | | $10.07 | $10.07 | $10.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.12 / $7.02 / $9.38
| Professional | | $4.12 | $7.02 | $9.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.07 / $10.07 / $10.07
| Facility | | $10.07 | $10.07 | $10.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.12 / $7.02 / $9.38
| Professional | | $4.12 | $7.02 | $9.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.61 / $5.03 / $11.73
| Professional | | $3.61 | $5.03 | $11.73 |