- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.88 / $10.70 / $51.43
| Professional | | $4.88 | $10.70 | $51.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.72 / $18.72 / $18.72
| Facility | | $18.72 | $18.72 | $18.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.28 / $18.72 / $18.72
| Professional | | $7.28 | $18.72 | $18.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.38 / $16.97 / $18.72
| Facility | | $13.38 | $16.97 | $18.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.05 / $14.05 / $20.89
| Professional | | $14.05 | $14.05 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.83 / $7.56 / $8.89
| Professional | | $6.83 | $7.56 | $8.89 |