- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.72 / $25.72 / $25.72
| Professional | | $25.72 | $25.72 | $25.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.62 / $118.15 / $261.42
| Facility | | $112.62 | $118.15 | $261.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.18 / $25.18 / $157.69
| Facility | | $25.18 | $25.18 | $157.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.46 / $17.35 / $23.65
| Professional | | $10.46 | $17.35 | $23.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.18 / $25.18 / $157.69
| Facility | | $25.18 | $25.18 | $157.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.48 / $17.35 / $23.65
| Professional | | $5.48 | $17.35 | $23.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.57 / $12.35 / $40.81
| Professional | | $6.57 | $12.35 | $40.81 |