- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.83 / $11.57 / $11.57
| Professional | | $4.83 | $11.57 | $11.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.55 / $32.74 / $63.36
| Facility | | $25.55 | $32.74 | $63.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.87 / $13.87 / $13.87
| Professional | | $13.87 | $13.87 | $13.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.40 / $10.29 / $10.29
| Facility | | $5.40 | $10.29 | $10.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.40 / $8.75 / $10.60
| Professional | | $5.40 | $8.75 | $10.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.40 / $10.29 / $10.29
| Facility | | $5.40 | $10.29 | $10.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.40 / $10.09 / $10.60
| Professional | | $5.40 | $10.09 | $10.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.93 / $10.42 / $19.80
| Professional | | $5.93 | $10.42 | $19.80 |