- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.17 / $27.73 / $45.38
| Professional | | $16.17 | $27.73 | $45.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.44 / $24.44 / $51.49
| Facility | | $24.44 | $24.44 | $51.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.77 / $24.44 / $61.13
| Professional | | $20.77 | $24.44 | $61.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.76 / $39.44 / $247.53
| Facility | | $16.76 | $39.44 | $247.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.60 / $27.61 / $41.31
| Professional | | $17.60 | $27.61 | $41.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.55 / $26.33 / $40.67
| Professional | | $17.55 | $26.33 | $40.67 |