- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.12 / $21.35 / $44.75
| Professional | | $17.12 | $21.35 | $44.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.83 / $52.83 / $58.12
| Facility | | $52.83 | $52.83 | $58.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.55 / $17.30 / $19.77
| Professional | | $16.55 | $17.30 | $19.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.26 / $26.32 / $102.48
| Professional | | $17.26 | $26.32 | $102.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.41 / $24.55 / $179.92
| Facility | | $18.41 | $24.55 | $179.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.98 / $39.68 / $913.97
| Professional | | $17.98 | $39.68 | $913.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.79 / $26.26 / $88.80
| Professional | | $17.79 | $26.26 | $88.80 |