- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $26.50
| Facility | | $10.30 | $10.30 | $26.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $13.84
| Professional | | $10.30 | $10.30 | $13.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.25 / $29.66 / $33.29
| Professional | | $22.25 | $29.66 | $33.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.93 / $17.10 / $21.50
| Professional | | $16.93 | $17.10 | $21.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.30 / $22.08 / $85.85
| Facility | | $10.30 | $22.08 | $85.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.82 / $17.66 / $25.02
| Professional | | $6.82 | $17.66 | $25.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.18 / $10.00 / $24.50
| Professional | | $6.18 | $10.00 | $24.50 |