- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.48 / $16.64 / $16.64
| Facility | | $13.48 | $16.64 | $16.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.03 / $13.90 / $18.47
| Professional | | $12.03 | $13.90 | $18.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.91 / $18.75 / $25.00
| Professional | | $12.91 | $18.75 | $25.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.39 / $17.39 / $17.39
| Professional | | $17.39 | $17.39 | $17.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.48 / $19.28 / $38.40
| Facility | | $13.48 | $19.28 | $38.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.04 / $283.32 / $283.32
| Professional | | $14.04 | $283.32 | $283.32 |