- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.36 / $10.76 / $12.30
| Facility | | $8.36 | $10.76 | $12.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.25 / $10.76 / $13.83
| Professional | | $10.25 | $10.76 | $13.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.63 / $10.25 / $10.25
| Facility | | $5.63 | $10.25 | $10.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.25 / $10.25 / $10.25
| Professional | | $10.25 | $10.25 | $10.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.84 / $10.25 / $13.33
| Professional | | $9.84 | $10.25 | $13.33 |