- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.70 / $10.70 / $10.70
| Facility | | $10.70 | $10.70 | $10.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.46 / $10.70 / $15.61
| Professional | | $5.46 | $10.70 | $15.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.75 / $15.70 / $37.08
| Professional | | $12.75 | $15.70 | $37.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.28 / $7.28 / $7.28
| Professional | | $7.28 | $7.28 | $7.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.70 / $17.82 / $31.88
| Facility | | $10.70 | $17.82 | $31.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.83 / $7.56 / $88.79
| Professional | | $6.83 | $7.56 | $88.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.92 / $7.56 / $11.38
| Professional | | $5.92 | $7.56 | $11.38 |