- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.05 / $177.09 / $187.55
| Facility | | $0.05 | $177.09 | $187.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.05 / $0.05 / $0.05
| Professional | | $0.05 | $0.05 | $0.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.78 / $24.78 / $30.98
| Professional | | $24.78 | $24.78 | $30.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.54 / $23.88 / $27.93
| Professional | | $19.54 | $23.88 | $27.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.16 / $10.56 / $14.51
| Professional | | $10.16 | $10.56 | $14.51 |