- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.85 / $15.97 / $22.88
| Professional | | $13.85 | $15.97 | $22.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.71 / $21.87 / $26.37
| Professional | | $21.71 | $21.87 | $26.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.51 / $22.64 / $34.36
| Professional | | $17.51 | $22.64 | $34.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.52 / $36.52 / $36.52
| Facility | | $36.52 | $36.52 | $36.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.35 / $58.23 / $104.57
| Professional | | $15.35 | $58.23 | $104.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.90 / $165.54 / $210.08
| Professional | | $143.90 | $165.54 | $210.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.00 / $25.65 / $28.74
| Professional | | $21.00 | $25.65 | $28.74 |