- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.84 / $18.84 / $21.74
| Professional | | $18.84 | $18.84 | $21.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.10 / $23.10 / $28.38
| Facility | | $23.10 | $23.10 | $28.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.86 / $23.10 / $24.63
| Professional | | $16.86 | $23.10 | $24.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.10 / $23.10 / $28.38
| Facility | | $23.10 | $23.10 | $28.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.86 / $23.10 / $24.63
| Professional | | $16.86 | $23.10 | $24.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.85 / $22.87 / $44.64
| Professional | | $12.85 | $22.87 | $44.64 |