- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.68 / $26.68 / $142.94
| Professional | | $26.68 | $26.68 | $142.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.14 / $55.65 / $80.80
| Professional | | $30.14 | $55.65 | $80.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.46 / $34.46 / $36.22
| Professional | | $34.46 | $34.46 | $36.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.05 / $34.57 / $47.04
| Facility | | $31.05 | $34.57 | $47.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.56 / $30.90 / $72.59
| Professional | | $25.56 | $30.90 | $72.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.34 / $18.54 / $42.24
| Professional | | $13.34 | $18.54 | $42.24 |