- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.55 / $18.55 / $18.55
| Facility | | $18.55 | $18.55 | $18.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.74 / $13.39 / $13.39
| Professional | | $12.74 | $13.39 | $13.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.48 / $10.48 / $10.48
| Facility | | $10.48 | $10.48 | $10.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.54 / $18.59 / $29.94
| Professional | | $11.54 | $18.59 | $29.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.77 / $9.68 / $22.52
| Professional | | $6.77 | $9.68 | $22.52 |