- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.96 / $14.13 / $21.88
| Professional | | $10.96 | $14.13 | $21.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.22 / $16.22 / $25.12
| Facility | | $16.22 | $16.22 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $28.18 / $39.81
| Professional | | $16.22 | $28.18 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.88
| Professional | | $32.36 | $32.36 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.50 / $32.36 / $37.15
| Professional | | $19.50 | $32.36 | $37.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.98 / $17.38 / $20.42
| Facility | | $16.98 | $17.38 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.14 / $21.88 / $34.67
| Professional | | $15.14 | $21.88 | $34.67 |