- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.93 / $22.70 / $28.24
| Professional | | $16.93 | $22.70 | $28.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.32 / $18.32 / $18.32
| Professional | | $18.32 | $18.32 | $18.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.37 / $28.28 / $33.08
| Professional | | $21.37 | $28.28 | $33.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.85 / $16.85 / $18.52
| Facility | | $16.85 | $16.85 | $18.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.21 / $27.78 / $39.61
| Professional | | $15.21 | $27.78 | $39.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.61 / $20.43 / $36.11
| Professional | | $13.61 | $20.43 | $36.11 |