- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.97 / $13.08 / $17.52
| Professional | | $11.97 | $13.08 | $17.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.85 / $21.85 / $28.68
| Facility | | $21.85 | $21.85 | $28.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.57 / $21.85 / $28.68
| Professional | | $18.57 | $21.85 | $28.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.85 / $21.85 / $28.68
| Facility | | $21.85 | $21.85 | $28.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.85 / $21.85 / $28.68
| Professional | | $21.85 | $21.85 | $28.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.35 / $21.31 / $27.13
| Professional | | $10.35 | $21.31 | $27.13 |