- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.67 / $15.67 / $15.67
| Facility | | $15.67 | $15.67 | $15.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.67 / $15.67 / $19.71
| Professional | | $10.67 | $15.67 | $19.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.80 / $12.80 / $13.12
| Professional | | $12.80 | $12.80 | $13.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.09 / $15.09 / $15.09
| Professional | | $15.09 | $15.09 | $15.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.34 / $37.79 / $54.66
| Professional | | $20.34 | $37.79 | $54.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.16 / $13.22 / $20.32
| Professional | | $10.16 | $13.22 | $20.32 |