- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.45 / $20.74 / $22.24
| Facility | | $19.45 | $20.74 | $22.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.13 / $20.74 / $23.20
| Professional | | $17.13 | $20.74 | $23.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.00 / $27.00 / $52.11
| Facility | | $27.00 | $27.00 | $52.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.63 / $26.21 / $36.66
| Professional | | $19.63 | $26.21 | $36.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $20.72
| Professional | | $20.72 | $20.72 | $20.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.00 / $38.00 / $55.00
| Professional | | $38.00 | $38.00 | $55.00 |