- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.15 / $22.15 / $22.15
| Professional | | $22.15 | $22.15 | $22.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.41 / $144.63 / $225.29
| Facility | | $98.41 | $144.63 | $225.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.66 / $15.66 / $15.66
| Professional | | $15.66 | $15.66 | $15.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.22 / $21.22 / $155.10
| Facility | | $21.22 | $21.22 | $155.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.75 / $14.46 / $19.98
| Professional | | $8.75 | $14.46 | $19.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.22 / $21.22 / $155.10
| Facility | | $21.22 | $21.22 | $155.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.48 / $14.46 / $19.98
| Professional | | $5.48 | $14.46 | $19.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.54 / $10.64 / $24.84
| Professional | | $5.54 | $10.64 | $24.84 |