- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.14 / $28.74 / $28.74
| Professional | | $5.14 | $28.74 | $28.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.48 / $8.72 / $13.21
| Facility | | $6.48 | $8.72 | $13.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.21 / $6.48 / $6.71
| Professional | | $2.21 | $6.48 | $6.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.72 / $7.60 / $13.21
| Facility | | $4.72 | $7.60 | $13.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.01 / $4.01 / $6.48
| Professional | | $4.01 | $4.01 | $6.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.86 / $1.88 / $4.47
| Professional | | $1.86 | $1.88 | $4.47 |