- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.35 / $57.87 / $57.87
| Professional | | $10.35 | $57.87 | $57.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.05 / $17.55 / $26.60
| Facility | | $13.05 | $17.55 | $26.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.76 / $12.91 / $13.05
| Professional | | $4.76 | $12.91 | $13.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.00 / $15.30 / $26.60
| Facility | | $10.00 | $15.30 | $26.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.10 / $8.10 / $13.05
| Professional | | $8.10 | $8.10 | $13.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.00 / $9.00 / $9.00
| Facility | | $9.00 | $9.00 | $9.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.78 / $3.78 / $9.47
| Professional | | $3.78 | $3.78 | $9.47 |