- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.72 / $15.85 / $19.50
| Professional | | $10.72 | $15.85 | $19.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.62 / $104.71 / $112.20
| Facility | | $18.62 | $104.71 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.61 / $10.23 / $15.49
| Professional | | $6.61 | $10.23 | $15.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.03 / $14.45 / $28.18
| Facility | | $6.03 | $14.45 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.89 / $10.23 / $14.45
| Professional | | $5.89 | $10.23 | $14.45 |