- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.73 / $20.73 / $21.56
| Professional | | $20.73 | $20.73 | $21.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.55 / $19.35 / $22.11
| Professional | | $12.55 | $19.35 | $22.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.61 / $32.11 / $116.65
| Professional | | $8.61 | $32.11 | $116.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.79 / $56.18 / $56.18
| Professional | | $31.79 | $56.18 | $56.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.57 / $16.57 / $27.64
| Professional | | $16.57 | $16.57 | $27.64 |