- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.80 / $12.70 / $15.07
| Professional | | $10.80 | $12.70 | $15.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.31 / $13.55 / $23.01
| Facility | | $12.31 | $13.55 | $23.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.35 / $13.35 / $13.55
| Professional | | $13.35 | $13.35 | $13.55 |
- 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
- $12.78 / $24.00 / $37.00
| Professional | | $12.78 | $24.00 | $37.00 |