- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.40 / $26.83 / $52.25
| Facility | | $5.40 | $26.83 | $52.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.40 / $5.40 / $5.40
| Professional | | $5.40 | $5.40 | $5.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.48 / $32.83 / $75.08
| Professional | | $6.48 | $32.83 | $75.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.70 / $12.17 / $26.19
| Facility | | $11.70 | $12.17 | $26.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.01 / $8.26 / $10.33
| Professional | | $4.01 | $8.26 | $10.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.64 / $14.64 / $14.64
| Professional | | $14.64 | $14.64 | $14.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.32 / $5.83 / $6.55
| Professional | | $4.32 | $5.83 | $6.55 |