- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.48 / $19.48 / $19.88
| Facility | | $19.48 | $19.48 | $19.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.23 / $16.10 / $19.88
| Professional | | $10.23 | $16.10 | $19.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.97 / $10.97 / $22.70
| Professional | | $10.97 | $10.97 | $22.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.66 / $11.59 / $18.91
| Professional | | $10.66 | $11.59 | $18.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.04 / $29.51 / $39.72
| Professional | | $12.04 | $29.51 | $39.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.54 / $9.63 / $16.05
| Professional | | $7.54 | $9.63 | $16.05 |