- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.94 / $23.56 / $23.56
| Professional | | $21.94 | $23.56 | $23.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.66 / $195.25 / $535.38
| Facility | | $104.66 | $195.25 | $535.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.58 / $20.58 / $20.58
| Professional | | $20.58 | $20.58 | $20.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.91 / $27.91 / $563.79
| Facility | | $27.91 | $27.91 | $563.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.49 / $19.41 / $26.50
| Professional | | $11.49 | $19.41 | $26.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.91 / $27.91 / $563.79
| Facility | | $27.91 | $27.91 | $563.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.38 / $13.66 / $26.50
| Professional | | $13.38 | $13.66 | $26.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.28 / $11.32 / $26.40
| Professional | | $7.28 | $11.32 | $26.40 |