- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.20 / $21.20 / $22.01
| Facility | | $21.20 | $21.20 | $22.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.54 / $17.54 / $21.20
| Professional | | $17.54 | $17.54 | $21.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.00 / $26.00 / $31.00
| Professional | | $14.00 | $26.00 | $31.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.64 / $19.64 / $27.40
| Professional | | $19.64 | $19.64 | $27.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.02 / $33.47 / $61.22
| Professional | | $25.02 | $33.47 | $61.22 |