- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.36 / $10.36 / $10.36
| Professional | | $10.36 | $10.36 | $10.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.22 / $57.22 / $57.22
| Facility | | $57.22 | $57.22 | $57.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.24 / $39.24 / $49.04
| Professional | | $39.24 | $39.24 | $49.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.22 / $57.22 / $57.22
| Facility | | $57.22 | $57.22 | $57.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.79 / $39.24 / $49.04
| Professional | | $22.79 | $39.24 | $49.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.93 / $21.04 / $49.08
| Professional | | $14.93 | $21.04 | $49.08 |