- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.03 / $6.36 / $11.03
| Professional | | $5.03 | $6.36 | $11.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.78 / $29.47 / $34.89
| Facility | | $21.78 | $29.47 | $34.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.89 / $8.10 / $13.56
| Professional | | $6.89 | $8.10 | $13.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.50 / $10.29 / $12.72
| Facility | | $9.50 | $10.29 | $12.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.75 / $10.29 / $12.72
| Professional | | $8.75 | $10.29 | $12.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.03 / $8.55 / $12.82
| Professional | | $6.03 | $8.55 | $12.82 |