- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.43 / $18.43 / $18.43
| Professional | | $18.43 | $18.43 | $18.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.75 / $32.75 / $32.75
| Facility | | $32.75 | $32.75 | $32.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.29 / $20.63 / $25.78
| Professional | | $10.29 | $20.63 | $25.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.75 / $32.75 / $32.75
| Facility | | $32.75 | $32.75 | $32.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.72 / $20.63 / $25.78
| Professional | | $12.72 | $20.63 | $25.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.55 / $11.74 / $42.98
| Professional | | $8.55 | $11.74 | $42.98 |