- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.00 / $12.00 / $15.00
| Professional | | $12.00 | $12.00 | $15.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.93 / $42.83 / $49.53
| Facility | | $21.93 | $42.83 | $49.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.64 / $21.93 / $21.93
| Professional | | $18.64 | $21.93 | $21.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.22 / $22.22 / $22.22
| Facility | | $22.22 | $22.22 | $22.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $22.26 / $24.10
| Professional | | $16.22 | $22.26 | $24.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.67 / $16.42 / $24.48
| Professional | | $11.67 | $16.42 | $24.48 |