- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.50 / $11.86 / $15.15
| Professional | | $10.50 | $11.86 | $15.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.92 / $244.64 / $311.81
| Facility | | $190.92 | $244.64 | $311.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.82 / $19.82 / $19.82
| Professional | | $19.82 | $19.82 | $19.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.35 / $60.38 / $60.62
| Facility | | $34.35 | $60.38 | $60.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.29 / $15.77 / $28.59
| Professional | | $6.29 | $15.77 | $28.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.30 / $12.95 / $30.36
| Professional | | $5.30 | $12.95 | $30.36 |