- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.43 / $22.43 / $22.43
| Professional | | $22.43 | $22.43 | $22.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.08 / $36.71 / $93.56
| Facility | | $22.08 | $36.71 | $93.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.97 / $22.97 / $22.97
| Professional | | $22.97 | $22.97 | $22.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.08 / $36.71 / $93.56
| Facility | | $22.08 | $36.71 | $93.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.72 / $22.65 / $27.02
| Professional | | $14.72 | $22.65 | $27.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.52 / $22.52 / $22.52
| Professional | | $22.52 | $22.52 | $22.52 |