- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.79 / $127.44 / $127.44
| Professional | | $22.79 | $127.44 | $127.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.74 / $38.65 / $58.57
| Facility | | $28.74 | $38.65 | $58.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.89 / $28.39 / $28.74
| Professional | | $10.89 | $28.39 | $28.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.11 / $33.69 / $58.57
| Facility | | $23.11 | $33.69 | $58.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.84 / $17.84 / $28.74
| Professional | | $17.84 | $17.84 | $28.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.32 / $8.32 / $21.86
| Professional | | $8.32 | $8.32 | $21.86 |