- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.67 / $7.43 / $12.43
| Professional | | $5.67 | $7.43 | $12.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.43 / $34.32 / $40.63
| Facility | | $25.43 | $34.32 | $40.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.03 / $9.46 / $15.80
| Professional | | $8.03 | $9.46 | $15.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.00 / $11.60 / $14.33
| Facility | | $4.00 | $11.60 | $14.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.86 / $11.60 / $14.33
| Professional | | $9.86 | $11.60 | $14.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.78 / $8.97 / $14.95
| Professional | | $6.78 | $8.97 | $14.95 |