- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.00 / $60.55 / $60.55
| Professional | | $18.00 | $60.55 | $60.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.91 / $19.47 / $22.03
| Facility | | $13.91 | $19.47 | $22.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.91 / $15.77 / $22.03
| Professional | | $13.91 | $15.77 | $22.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.22 / $20.98 / $22.03
| Facility | | $10.22 | $20.98 | $22.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.91 / $16.53 / $22.04
| Professional | | $13.91 | $16.53 | $22.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.03 / $8.90 / $10.47
| Professional | | $8.03 | $8.90 | $10.47 |