- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.07 / $44.52 / $60.56
| Professional | | $22.07 | $44.52 | $60.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.85 / $25.76 / $71.25
| Professional | | $21.85 | $25.76 | $71.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.65 / $25.65 / $25.65
| Professional | | $25.65 | $25.65 | $25.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.42 / $60.56 / $90.84
| Facility | | $45.42 | $60.56 | $90.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.25 / $92.63 / $141.08
| Professional | | $71.25 | $92.63 | $141.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.10 / $26.66 / $38.25
| Professional | | $24.10 | $26.66 | $38.25 |