- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.00 / $15.24 / $310.04
| Facility | | $11.00 | $15.24 | $310.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $11.00 / $11.00
| Professional | | $10.47 | $11.00 | $11.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.61 / $8.61 / $8.61
| Facility | | $8.61 | $8.61 | $8.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.52 / $15.28 / $22.58
| Professional | | $8.52 | $15.28 | $22.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.57 / $6.75 / $16.76
| Professional | | $5.57 | $6.75 | $16.76 |