- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.63 / $20.63 / $20.63
| Professional | | $20.63 | $20.63 | $20.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.69 / $140.33 / $209.83
| Facility | | $91.69 | $140.33 | $209.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.60 / $14.60 / $14.60
| Professional | | $14.60 | $14.60 | $14.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.78 / $19.78 / $150.47
| Facility | | $19.78 | $19.78 | $150.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.23 / $13.63 / $18.75
| Professional | | $8.23 | $13.63 | $18.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.78 / $19.78 / $150.47
| Facility | | $19.78 | $19.78 | $150.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.48 / $13.63 / $18.75
| Professional | | $5.48 | $13.63 | $18.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.25 / $9.91 / $23.13
| Professional | | $5.25 | $9.91 | $23.13 |