- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.42 / $34.53 / $193.09
| Professional | | $23.42 | $34.53 | $193.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.24 / $40.24 / $40.24
| Professional | | $40.24 | $40.24 | $40.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.54 / $51.05 / $171.17
| Facility | | $43.54 | $51.05 | $171.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.78 / $43.54 / $43.54
| Professional | | $13.78 | $43.54 | $43.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.54 / $51.05 / $171.17
| Facility | | $43.54 | $51.05 | $171.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.03 / $27.03 / $43.54
| Professional | | $27.03 | $27.03 | $43.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.47 / $12.61 / $30.03
| Professional | | $11.47 | $12.61 | $30.03 |