- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.53 / $20.53 / $22.08
| Facility | | $20.53 | $20.53 | $22.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.38 / $20.53 / $21.22
| Professional | | $16.38 | $20.53 | $21.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.75 / $25.00 / $31.43
| Professional | | $24.75 | $25.00 | $31.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.13 / $20.53 / $115.05
| Facility | | $11.13 | $20.53 | $115.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.67 / $16.32 / $24.43
| Professional | | $11.67 | $16.32 | $24.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.66 / $16.42 / $23.68
| Professional | | $8.66 | $16.42 | $23.68 |