- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.62 / $14.10 / $14.10
| Professional | | $10.62 | $14.10 | $14.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $62.62 / $108.73 / $144.47
| Facility | | $62.62 | $108.73 | $144.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.97 / $9.97 / $9.97
| Professional | | $9.97 | $9.97 | $9.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.52 / $13.52 / $94.20
| Facility | | $13.52 | $13.52 | $94.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.66 / $9.50 / $12.64
| Professional | | $5.66 | $9.50 | $12.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.52 / $13.52 / $94.20
| Facility | | $13.52 | $13.52 | $94.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.66 / $9.50 / $12.64
| Professional | | $5.66 | $9.50 | $12.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.84 / $6.77 / $15.81
| Professional | | $4.84 | $6.77 | $15.81 |