- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.82 / $20.82 / $23.92
| Professional | | $18.82 | $20.82 | $23.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.53 / $37.39 / $69.31
| Facility | | $31.53 | $37.39 | $69.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.74 / $20.74 / $25.32
| Professional | | $20.74 | $20.74 | $25.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $31.41
| Facility | | $20.72 | $20.72 | $31.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.61 / $20.72 / $24.62
| Professional | | $17.61 | $20.72 | $24.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.92 / $25.92 / $25.92
| Professional | | $25.92 | $25.92 | $25.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.01 / $18.82 / $23.92
| Professional | | $15.01 | $18.82 | $23.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.66 / $24.96 / $48.95
| Professional | | $11.66 | $24.96 | $48.95 |