- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.60 / $14.48 / $14.48
| Professional | | $11.60 | $14.48 | $14.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.05 / $15.40 / $15.62
| Professional | | $13.05 | $15.40 | $15.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.88 / $20.07 / $25.24
| Professional | | $19.88 | $20.07 | $25.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.60 / $12.00 / $17.30
| Facility | | $11.60 | $12.00 | $17.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.56 / $6.89 / $124.16
| Professional | | $5.56 | $6.89 | $124.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.45 / $5.56 / $17.30
| Professional | | $5.45 | $5.56 | $17.30 |