- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.18 / $56.91 / $56.91
| Professional | | $10.18 | $56.91 | $56.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.83 / $17.26 / $26.15
| Facility | | $12.83 | $17.26 | $26.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.12 / $12.39 / $12.83
| Professional | | $6.12 | $12.39 | $12.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.83 / $15.05 / $26.15
| Facility | | $12.83 | $15.05 | $26.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.97 / $8.85 / $12.83
| Professional | | $7.97 | $8.85 | $12.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.72 / $3.72 / $12.16
| Professional | | $3.72 | $3.72 | $12.16 |