- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.84 / $21.84 / $21.84
| Professional | | $21.84 | $21.84 | $21.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.60 / $32.60 / $32.60
| Facility | | $32.60 | $32.60 | $32.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $32.60
| Professional | | $21.05 | $21.05 | $32.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.60 / $32.60 / $32.60
| Facility | | $32.60 | $32.60 | $32.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $29.45 / $38.99
| Professional | | $21.05 | $29.45 | $38.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $21.05
| Professional | | $21.05 | $21.05 | $21.05 |