- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.30 / $17.28 / $52.89
| Facility | | $8.30 | $17.28 | $52.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.33 / $10.34 / $11.48
| Professional | | $10.33 | $10.34 | $11.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.34 / $10.34 / $13.32
| Professional | | $10.34 | $10.34 | $13.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.34 / $10.34 / $10.34
| Facility | | $10.34 | $10.34 | $10.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.34 / $10.34 / $12.48
| Professional | | $10.34 | $10.34 | $12.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.34 / $10.34 / $10.34
| Professional | | $10.34 | $10.34 | $10.34 |