- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.27 / $46.30 / $46.30
| Professional | | $8.27 | $46.30 | $46.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.44 / $14.04 / $21.28
| Facility | | $10.44 | $14.04 | $21.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.59 / $10.33 / $10.44
| Professional | | $4.59 | $10.33 | $10.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.60 / $12.24 / $21.28
| Facility | | $9.60 | $12.24 | $21.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.48 / $6.48 / $10.44
| Professional | | $6.48 | $6.48 | $10.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $3.02 / $9.08
| Professional | | $3.02 | $3.02 | $9.08 |