- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.36 / $44.36 / $44.36
| Facility | | $44.36 | $44.36 | $44.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.47 / $32.01 / $32.01
| Professional | | $30.47 | $32.01 | $32.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.71 / $44.19 / $55.24
| Professional | | $19.71 | $44.19 | $55.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.60 / $102.60 / $102.60
| Facility | | $102.60 | $102.60 | $102.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.50 / $16.20 / $38.57
| Professional | | $13.50 | $16.20 | $38.57 |