- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.28 / $10.28 / $10.28
| Facility | | $10.28 | $10.28 | $10.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.28 / $12.52 / $17.64
| Professional | | $10.28 | $12.52 | $17.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.00 / $20.00 / $38.60
| Facility | | $20.00 | $20.00 | $38.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $21.55 / $28.40
| Professional | | $20.00 | $21.55 | $28.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.64 / $17.39 / $17.93
| Professional | | $13.64 | $17.39 | $17.93 |