- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.14 / $20.14 / $103.75
| Professional | | $20.14 | $20.14 | $103.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.01 / $106.04 / $176.70
| Facility | | $27.01 | $106.04 | $176.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.54 / $32.79 / $65.38
| Professional | | $22.54 | $32.79 | $65.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.14 / $16.14 / $16.14
| Professional | | $16.14 | $16.14 | $16.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.15 / $46.40 / $168.29
| Facility | | $22.15 | $46.40 | $168.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.54 / $27.34 / $54.83
| Professional | | $23.54 | $27.34 | $54.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.64 / $28.46 / $54.83
| Professional | | $23.64 | $28.46 | $54.83 |