- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.52 / $60.52 / $60.52
| Facility | | $60.52 | $60.52 | $60.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.35 / $11.68 / $13.40
| Professional | | $8.35 | $11.68 | $13.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.78 / $14.20 / $21.76
| Professional | | $12.78 | $14.20 | $21.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.36 / $10.37 / $20.43
| Facility | | $8.36 | $10.37 | $20.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.36 / $15.47 / $23.51
| Professional | | $8.36 | $15.47 | $23.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.78 / $19.73 / $23.67
| Professional | | $15.78 | $19.73 | $23.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.10 / $8.93 / $14.36
| Professional | | $7.10 | $8.93 | $14.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.15 / $7.89 / $14.29
| Professional | | $6.15 | $7.89 | $14.29 |