- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.20 / $13.48 / $15.28
| Professional | | $12.20 | $13.48 | $15.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.64 / $21.95 / $23.86
| Facility | | $18.64 | $21.95 | $23.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.98 / $13.98 / $22.78
| Professional | | $13.98 | $13.98 | $22.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.44 / $21.48 / $26.85
| Professional | | $10.44 | $21.48 | $26.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.37 / $22.37 / $22.37
| Facility | | $22.37 | $22.37 | $22.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.52 / $11.18 / $26.88
| Professional | | $6.52 | $11.18 | $26.88 |