- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.74 / $37.68 / $37.68
| Professional | | $6.74 | $37.68 | $37.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.50 / $11.43 / $17.32
| Facility | | $8.50 | $11.43 | $17.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.08 / $8.26 / $8.50
| Professional | | $4.08 | $8.26 | $8.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.50 / $9.96 / $17.32
| Facility | | $8.50 | $9.96 | $17.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.27 / $5.86 / $8.50
| Professional | | $5.27 | $5.86 | $8.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.46 / $2.46 / $8.06
| Professional | | $2.46 | $2.46 | $8.06 |