- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.03 / $0.06
| Facility | | $0.02 | $0.03 | $0.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.03
| Professional | | $0.02 | $0.02 | $0.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.97 / $7.14 / $10.91
| Professional | | $6.97 | $7.14 | $10.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.69 / $15.69 / $19.62
| Professional | | $15.69 | $15.69 | $19.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.39 / $14.39 / $14.39
| Facility | | $14.39 | $14.39 | $14.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.00 / $162.00 / $162.00
| Professional | | $162.00 | $162.00 | $162.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.23 / $13.23 / $13.23
| Facility | | $13.23 | $13.23 | $13.23 |