- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.75 / $2.83 / $10.50
| Professional | | $2.75 | $2.83 | $10.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.15 / $13.65 / $20.69
| Facility | | $10.15 | $13.65 | $20.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.70 / $10.15 / $10.33
| Professional | | $1.70 | $10.15 | $10.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.44 / $11.90 / $20.69
| Facility | | $3.44 | $11.90 | $20.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.30 / $6.30 / $10.15
| Professional | | $6.30 | $6.30 | $10.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.94 / $4.20 / $7.00
| Professional | | $1.94 | $4.20 | $7.00 |