- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.78 / $16.78 / $19.37
| Professional | | $16.78 | $16.78 | $19.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.58 / $23.58 / $23.58
| Facility | | $23.58 | $23.58 | $23.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.21 / $22.63 / $25.14
| Professional | | $17.21 | $22.63 | $25.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.58 / $23.58 / $23.58
| Facility | | $23.58 | $23.58 | $23.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.21 / $23.58 / $25.14
| Professional | | $17.21 | $23.58 | $25.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.57 / $15.57 / $19.64
| Facility | | $15.57 | $15.57 | $19.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.44 / $20.37 / $39.77
| Professional | | $11.44 | $20.37 | $39.77 |