- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.67 / $10.67 / $10.67
| Facility | | $10.67 | $10.67 | $10.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.67 / $10.67 / $18.43
| Professional | | $10.67 | $10.67 | $18.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $50.16 / $56.62
| Facility | | $34.67 | $50.16 | $56.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.54 / $13.58 / $22.12
| Professional | | $11.54 | $13.58 | $22.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.09 / $15.09 / $15.09
| Professional | | $15.09 | $15.09 | $15.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.16 / $14.07 / $22.03
| Professional | | $10.16 | $14.07 | $22.03 |