- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $5.01 / $17.78
| Professional | | $5.01 | $5.01 | $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 / $20.42
| Professional | | $12.59 | $12.59 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.49 / $21.88 / $40.74
| Professional | | $13.49 | $21.88 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $15.14 / $40.74
| Professional | | $10.47 | $15.14 | $40.74 |