- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.50 / $5.50 / $5.50
| Facility | | $5.50 | $5.50 | $5.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.50 / $12.04 / $57.91
| Professional | | $5.50 | $12.04 | $57.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.26 / $10.26 / $10.26
| Professional | | $10.26 | $10.26 | $10.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.32 / $17.85 / $60.00
| Professional | | $16.32 | $17.85 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.16 / $14.05 / $14.05
| Professional | | $11.16 | $14.05 | $14.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.67 / $8.52 / $12.84
| Professional | | $6.67 | $8.52 | $12.84 |