- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.41 / $16.47 / $16.47
| Professional | | $12.41 | $16.47 | $16.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.13 / $112.22 / $168.55
| Facility | | $73.13 | $112.22 | $168.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.66 / $11.66 / $11.66
| Professional | | $11.66 | $11.66 | $11.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.81 / $15.81 / $106.37
| Facility | | $15.81 | $15.81 | $106.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.52 / $10.74 / $15.09
| Professional | | $6.52 | $10.74 | $15.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.81 / $15.81 / $106.37
| Facility | | $15.81 | $15.81 | $106.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.52 / $10.74 / $15.09
| Professional | | $6.52 | $10.74 | $15.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.66 / $7.91 / $18.45
| Professional | | $5.66 | $7.91 | $18.45 |