- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.62 / $5.62 / $17.78
| Professional | | $5.62 | $5.62 | $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 / $30.90
| Professional | | $12.59 | $12.59 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.79 / $24.55 / $35.48
| Professional | | $14.79 | $24.55 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $15.14 / $31.62
| Professional | | $10.47 | $15.14 | $31.62 |