- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.55 / $10.17 / $10.76
| Professional | | $7.55 | $10.17 | $10.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.00 / $12.94 / $22.28
| Professional | | $11.00 | $12.94 | $22.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.93 / $13.93 / $13.93
| Facility | | $13.93 | $13.93 | $13.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.84 / $13.93 / $13.93
| Professional | | $11.84 | $13.93 | $13.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.05 / $14.07 / $20.48
| Professional | | $8.05 | $14.07 | $20.48 |