- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.91 / $26.32 / $28.39
| Professional | | $20.91 | $26.32 | $28.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.67 / $91.41 / $108.23
| Facility | | $67.67 | $91.41 | $108.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.13 / $34.27 / $43.29
| Professional | | $29.13 | $34.27 | $43.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.72 / $33.72 / $33.72
| Facility | | $33.72 | $33.72 | $33.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.62 / $33.72 / $33.72
| Professional | | $24.62 | $33.72 | $33.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.41 / $58.41 / $58.41
| Facility | | $58.41 | $58.41 | $58.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.70 / $26.95 / $39.81
| Professional | | $18.70 | $26.95 | $39.81 |