- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.25 / $17.51 / $17.51
| Professional | | $10.25 | $17.51 | $17.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77.75 / $170.27 / $178.87
| Facility | | $77.75 | $170.27 | $178.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.27 / $21.27 / $21.27
| Facility | | $21.27 | $21.27 | $21.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.03 / $14.46 / $18.07
| Professional | | $7.03 | $14.46 | $18.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.27 / $21.27 / $21.27
| Facility | | $21.27 | $21.27 | $21.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.03 / $14.46 / $18.07
| Professional | | $7.03 | $14.46 | $18.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.92 / $14.02 / $19.63
| Professional | | $7.92 | $14.02 | $19.63 |