- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.51 / $16.51 / $16.51
| Professional | | $16.51 | $16.51 | $16.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.06 / $30.06 / $56.84
| Facility | | $30.06 | $30.06 | $56.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.06 / $30.96 / $55.73
| Professional | | $30.06 | $30.96 | $55.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.55 / $34.63 / $56.84
| Facility | | $17.55 | $34.63 | $56.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.06 / $51.44 / $66.78
| Professional | | $30.06 | $51.44 | $66.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.65 / $22.95 / $27.83
| Professional | | $21.65 | $22.95 | $27.83 |