- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.46 / $6.46 / $17.78
| Professional | | $6.46 | $6.46 | $17.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.35 / $2.75 / $3.16
| Facility | | $1.35 | $2.75 | $3.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.59 / $12.59 / $33.88
| Professional | | $12.59 | $12.59 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $28.18 / $54.95
| Professional | | $16.22 | $28.18 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $15.14 / $53.70
| Professional | | $10.47 | $15.14 | $53.70 |