- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $30.71 / $44.00
| Professional | | $21.25 | $30.71 | $44.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.70 / $36.70 / $36.70
| Facility | | $36.70 | $36.70 | $36.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.86 / $38.54 / $49.55
| Professional | | $34.86 | $38.54 | $49.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.63 / $48.28 / $49.05
| Professional | | $38.63 | $48.28 | $49.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.92 / $30.71 / $33.69
| Professional | | $25.92 | $30.71 | $33.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.09 / $19.89 / $24.42
| Professional | | $18.09 | $19.89 | $24.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.14 / $28.87 / $39.69
| Professional | | $21.14 | $28.87 | $39.69 |