- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.71 / $10.71 / $20.56
| Facility | | $10.71 | $10.71 | $20.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.71 / $16.60 / $27.03
| Professional | | $10.71 | $16.60 | $27.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.37 / $15.96 / $15.96
| Facility | | $15.37 | $15.96 | $15.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.00 / $22.00 / $22.00
| Professional | | $22.00 | $22.00 | $22.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.25 / $20.12 / $28.74
| Professional | | $12.25 | $20.12 | $28.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $25.00 / $50.00
| Professional | | $17.00 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.71 / $22.67 / $31.54
| Professional | | $18.71 | $22.67 | $31.54 |