- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.72 / $12.72 / $12.72
| Facility | | $12.72 | $12.72 | $12.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.72 / $16.25 / $20.58
| Professional | | $12.72 | $16.25 | $20.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.64 / $25.64 / $37.36
| Facility | | $25.64 | $25.64 | $37.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.72 / $18.72 / $32.71
| Professional | | $18.72 | $18.72 | $32.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.11 / $34.36 / $48.94
| Professional | | $34.11 | $34.36 | $48.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.47 / $17.47 / $24.85
| Professional | | $17.47 | $17.47 | $24.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.46 / $18.64 / $37.36
| Professional | | $14.46 | $18.64 | $37.36 |