- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.78 / $18.89 / $18.89
| Professional | | $17.78 | $18.89 | $18.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.45 / $33.35 / $40.01
| Facility | | $24.45 | $33.35 | $40.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.68 / $26.68 / $30.01
| Professional | | $26.68 | $26.68 | $30.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.68 / $26.68 / $26.68
| Facility | | $26.68 | $26.68 | $26.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.32 / $27.31 / $71.37
| Professional | | $18.32 | $27.31 | $71.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.23 / $22.23 / $50.19
| Professional | | $12.23 | $22.23 | $50.19 |