- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.50 / $53.11 / $53.11
| Professional | | $9.50 | $53.11 | $53.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.98 / $16.11 / $24.41
| Facility | | $11.98 | $16.11 | $24.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.93 / $11.87 / $11.98
| Professional | | $4.93 | $11.87 | $11.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.61 / $14.04 / $24.41
| Facility | | $10.61 | $14.04 | $24.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.43 / $7.43 / $11.98
| Professional | | $7.43 | $7.43 | $11.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.47 / $3.47 / $10.02
| Professional | | $3.47 | $3.47 | $10.02 |