- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $21.78 / $21.78
| Professional | | $12.02 | $21.78 | $21.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.21 / $40.56 / $75.19
| Facility | | $34.21 | $40.56 | $75.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.20 / $23.32 / $26.78
| Professional | | $21.20 | $23.32 | $26.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.28 / $22.28 / $33.06
| Facility | | $22.28 | $22.28 | $33.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.94 / $22.28 / $26.23
| Professional | | $18.94 | $22.28 | $26.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.14 / $28.14 / $28.14
| Professional | | $28.14 | $28.14 | $28.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.56 / $12.02 / $21.78
| Professional | | $11.56 | $12.02 | $21.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.63 / $20.69 / $45.75
| Professional | | $11.63 | $20.69 | $45.75 |