- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.66 / $81.98 / $81.98
| Professional | | $14.66 | $81.98 | $81.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.48 / $24.86 / $37.68
| Facility | | $18.48 | $24.86 | $37.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.00 / $18.07 / $18.48
| Professional | | $8.00 | $18.07 | $18.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.91 / $21.68 / $37.68
| Facility | | $16.91 | $21.68 | $37.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $11.48 / $18.48
| Professional | | $11.48 | $11.48 | $18.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.36 / $5.36 / $15.99
| Professional | | $5.36 | $5.36 | $15.99 |