- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.50 / $120.83 / $120.83
| Professional | | $16.50 | $120.83 | $120.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.67 / $45.53 / $45.53
| Facility | | $26.67 | $45.53 | $45.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.67 / $45.53 / $45.53
| Professional | | $26.67 | $45.53 | $45.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.37 / $43.36 / $45.53
| Facility | | $21.37 | $43.36 | $45.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.67 / $34.17 / $45.56
| Professional | | $26.67 | $34.17 | $45.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.28 / $19.12 / $21.89
| Professional | | $17.28 | $19.12 | $21.89 |