- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.01 / $25.12 / $30.53
| Professional | | $21.01 | $25.12 | $30.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.38 / $165.38 / $165.38
| Facility | | $165.38 | $165.38 | $165.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.51 / $25.51 / $54.48
| Professional | | $25.51 | $25.51 | $54.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.29 / $32.29 / $32.29
| Professional | | $32.29 | $32.29 | $32.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.27 / $26.22 / $41.58
| Facility | | $21.27 | $26.22 | $41.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.84 / $25.84 / $26.22
| Professional | | $25.84 | $25.84 | $26.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.00 / $45.60 / $62.00
| Professional | | $26.00 | $45.60 | $62.00 |