- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.19 / $57.03 / $57.03
| Professional | | $10.19 | $57.03 | $57.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.86 / $17.30 / $26.21
| Facility | | $12.86 | $17.30 | $26.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.12 / $12.39 / $12.86
| Professional | | $6.12 | $12.39 | $12.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.86 / $15.08 / $26.21
| Facility | | $12.86 | $15.08 | $26.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.98 / $8.86 / $12.86
| Professional | | $7.98 | $8.86 | $12.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.73 / $3.83 / $12.20
| Professional | | $3.73 | $3.83 | $12.20 |