- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.42 / $16.42 / $16.42
| Facility | | $16.42 | $16.42 | $16.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.03 / $14.90 / $16.52
| Professional | | $12.03 | $14.90 | $16.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.15 / $37.81 / $44.25
| Professional | | $37.15 | $37.81 | $44.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.51 / $21.12 / $30.73
| Facility | | $15.51 | $21.12 | $30.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.03 / $283.32 / $283.32
| Professional | | $31.03 | $283.32 | $283.32 |