- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.65 / $5.65 / $14.53
| Facility | | $5.65 | $5.65 | $14.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.65 / $5.65 / $7.59
| Professional | | $5.65 | $5.65 | $7.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.20 / $16.26 / $18.25
| Professional | | $12.20 | $16.26 | $18.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.50 / $9.59 / $12.06
| Professional | | $9.50 | $9.59 | $12.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.65 / $10.53 / $60.00
| Facility | | $5.65 | $10.53 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.39 / $9.36 / $13.72
| Professional | | $3.39 | $9.36 | $13.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.39 / $8.23 / $13.72
| Professional | | $3.39 | $8.23 | $13.72 |