- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.78 / $77.03 / $77.03
| Professional | | $13.78 | $77.03 | $77.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.37 / $23.36 / $35.40
| Facility | | $17.37 | $23.36 | $35.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.17 / $17.04 / $17.37
| Professional | | $8.17 | $17.04 | $17.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.37 / $20.37 / $35.40
| Facility | | $17.37 | $20.37 | $35.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.78 / $11.98 / $17.37
| Professional | | $10.78 | $11.98 | $17.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.03 / $6.85 / $20.51
| Professional | | $5.03 | $6.85 | $20.51 |