- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.71 / $42.54 / $50.37
| Professional | | $21.71 | $42.54 | $50.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $51.42 / $63.27
| Professional | | $40.00 | $51.42 | $63.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.24 / $25.24 / $25.24
| Professional | | $25.24 | $25.24 | $25.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.00 / $42.54 / $56.58
| Facility | | $37.00 | $42.54 | $56.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.86 / $26.00 / $31.14
| Professional | | $21.86 | $26.00 | $31.14 |