- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.42 / $52.66 / $52.66
| Professional | | $9.42 | $52.66 | $52.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.88 / $15.97 / $24.20
| Facility | | $11.88 | $15.97 | $24.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.61 / $11.87 / $11.88
| Professional | | $5.61 | $11.87 | $11.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.88 / $13.92 / $24.20
| Facility | | $11.88 | $13.92 | $24.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.37 / $7.37 / $11.88
| Professional | | $7.37 | $7.37 | $11.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.44 / $3.44 / $8.19
| Professional | | $3.44 | $3.44 | $8.19 |