- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.22 / $18.22 / $18.22
| Professional | | $18.22 | $18.22 | $18.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.93 / $145.57 / $185.76
| Facility | | $80.93 | $145.57 | $185.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.34 / $16.34 / $16.34
| Professional | | $16.34 | $16.34 | $16.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.17 / $22.17 / $148.40
| Facility | | $22.17 | $22.17 | $148.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.09 / $15.28 / $20.79
| Professional | | $9.09 | $15.28 | $20.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.17 / $22.17 / $148.40
| Facility | | $22.17 | $22.17 | $148.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.09 / $15.28 / $20.79
| Professional | | $9.09 | $15.28 | $20.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.78 / $8.75 / $20.41
| Professional | | $5.78 | $8.75 | $20.41 |