- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.88 / $25.70 / $32.36
| Professional | | $21.88 | $25.70 | $32.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $141.25 / $323.59
| Facility | | $34.67 | $141.25 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $34.67
| Professional | | $34.67 | $34.67 | $34.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $46.77
| Facility | | $34.67 | $34.67 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.05 / $31.62 / $43.65
| Professional | | $19.05 | $31.62 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.54 / $27.54 / $27.54
| Facility | | $27.54 | $27.54 | $27.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.77 / $9.77 / $9.77
| Facility | | $9.77 | $9.77 | $9.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $16.60 / $75.86
| Professional | | $12.02 | $16.60 | $75.86 |