- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.05 / $13.53 / $14.21
| Professional | | $13.05 | $13.53 | $14.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.83 / $27.29 / $31.83
| Facility | | $21.83 | $27.29 | $31.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.83 / $21.83 / $24.56
| Professional | | $21.83 | $21.83 | $24.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $21.31
| Facility | | $21.31 | $21.31 | $21.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.23 / $19.72 / $87.68
| Professional | | $18.23 | $19.72 | $87.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.32 / $11.57 / $24.35
| Professional | | $8.32 | $11.57 | $24.35 |