- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.72 / $82.30 / $82.30
| Professional | | $14.72 | $82.30 | $82.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.55 / $24.96 / $37.82
| Facility | | $18.55 | $24.96 | $37.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.85 / $18.55 / $18.59
| Professional | | $8.85 | $18.55 | $18.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.55 / $21.76 / $37.82
| Facility | | $18.55 | $21.76 | $37.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.52 / $12.80 / $18.55
| Professional | | $11.52 | $12.80 | $18.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.38 / $5.38 / $17.60
| Professional | | $5.38 | $5.38 | $17.60 |