- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.40 / $17.68 / $27.87
| Professional | | $10.40 | $17.68 | $27.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.46 / $23.64 / $41.51
| Professional | | $15.46 | $23.64 | $41.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.75 / $101.75 / $101.75
| Facility | | $101.75 | $101.75 | $101.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.03 / $25.09 / $46.60
| Professional | | $15.03 | $25.09 | $46.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.96 / $36.46 / $49.89
| Professional | | $25.96 | $36.46 | $49.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.78 / $33.34 / $52.73
| Professional | | $21.78 | $33.34 | $52.73 |