- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.38 / $25.94 / $38.74
| Professional | | $20.38 | $25.94 | $38.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $106.33
| Facility | | $106.33 | $106.33 | $106.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.87 / $60.28 / $60.28
| Professional | | $58.87 | $60.28 | $60.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.70 / $21.70 / $21.70
| Professional | | $21.70 | $21.70 | $21.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.86 / $36.86 / $36.86
| Professional | | $36.86 | $36.86 | $36.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.38 / $25.94 / $38.74
| Professional | | $20.38 | $25.94 | $38.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.66 / $22.55 / $51.87
| Professional | | $17.66 | $22.55 | $51.87 |