- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.98 / $16.78 / $22.37
| Facility | | $15.98 | $16.78 | $22.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.94 / $13.26 / $15.98
| Professional | | $12.94 | $13.26 | $15.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.31 / $2.64 / $2.71
| Professional | | $2.31 | $2.64 | $2.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.58 / $13.58 / $85.00
| Facility | | $13.58 | $13.58 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.58 / $13.58 / $13.58
| Professional | | $13.58 | $13.58 | $13.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.44 / $1.90 / $3.30
| Professional | | $1.44 | $1.90 | $3.30 |