- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.43 / $20.35 / $30.45
| Professional | | $11.43 | $20.35 | $30.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.50 / $30.50 / $30.50
| Facility | | $30.50 | $30.50 | $30.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.45 / $30.50 / $45.82
| Professional | | $27.45 | $30.50 | $45.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.43 / $30.45 / $137.83
| Facility | | $11.43 | $30.45 | $137.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.50 / $30.50 / $45.82
| Professional | | $30.50 | $30.50 | $45.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.56 / $23.23 / $39.94
| Professional | | $22.56 | $23.23 | $39.94 |