- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.58 / $21.58 / $115.61
| Professional | | $21.58 | $21.58 | $115.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.41 / $22.94 / $33.00
| Professional | | $20.41 | $22.94 | $33.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.87 / $27.87 / $29.31
| Professional | | $27.87 | $27.87 | $29.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.02 / $24.17 / $31.86
| Facility | | $21.02 | $24.17 | $31.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.68 / $22.83 / $29.92
| Professional | | $20.68 | $22.83 | $29.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.79 / $12.55 / $31.46
| Professional | | $10.79 | $12.55 | $31.46 |