- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.68 / $10.68 / $18.16
| Facility | | $10.68 | $10.68 | $18.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.43 / $10.68 / $15.90
| Professional | | $10.43 | $10.68 | $15.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.87 / $7.87 / $7.87
| Professional | | $7.87 | $7.87 | $7.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.68 / $11.75 / $134.40
| Facility | | $10.68 | $11.75 | $134.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.57 / $12.57 / $18.57
| Professional | | $12.57 | $12.57 | $18.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.57 / $12.57 / $13.86
| Professional | | $12.57 | $12.57 | $13.86 |