- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.87 / $22.67 / $22.67
| Professional | | $17.87 | $22.67 | $22.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.22 / $43.05 / $79.80
| Facility | | $33.22 | $43.05 | $79.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.84 / $21.83 / $21.83
| Professional | | $20.84 | $21.83 | $21.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.64 / $25.64 / $25.64
| Facility | | $25.64 | $25.64 | $25.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.72 / $18.72 / $25.64
| Professional | | $18.72 | $18.72 | $25.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.25 / $30.25 / $30.25
| Professional | | $30.25 | $30.25 | $30.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.03 / $22.67 / $22.67
| Professional | | $21.03 | $22.67 | $22.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.15 / $18.64 / $42.85
| Professional | | $13.15 | $18.64 | $42.85 |