- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.98 / $61.41 / $61.41
| Professional | | $10.98 | $61.41 | $61.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.85 / $18.62 / $28.22
| Facility | | $13.85 | $18.62 | $28.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.93 / $13.85 / $13.94
| Professional | | $4.93 | $13.85 | $13.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.32 / $16.23 / $28.22
| Facility | | $10.32 | $16.23 | $28.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.60 / $8.60 / $13.85
| Professional | | $8.60 | $8.60 | $13.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.01 / $4.01 / $9.75
| Professional | | $4.01 | $4.01 | $9.75 |