- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.16 / $17.01 / $26.15
| Professional | | $16.16 | $17.01 | $26.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.67 / $55.15 / $69.29
| Facility | | $47.67 | $55.15 | $69.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.93 / $30.51 / $59.81
| Professional | | $25.93 | $30.51 | $59.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.81 / $23.81 / $23.81
| Professional | | $23.81 | $23.81 | $23.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.86 / $26.21 / $51.40
| Professional | | $12.86 | $26.21 | $51.40 |