- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.59 / $12.42 / $12.42
| Professional | | $11.59 | $12.42 | $12.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.74 / $16.10 / $46.70
| Professional | | $15.74 | $16.10 | $46.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.98 / $21.28 / $51.96
| Professional | | $11.98 | $21.28 | $51.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.22 / $30.51 / $30.51
| Professional | | $14.22 | $30.51 | $30.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.42 / $17.60 / $38.65
| Professional | | $11.42 | $17.60 | $38.65 |