- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.02 / $13.83 / $16.10
| Professional | | $11.02 | $13.83 | $16.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.62 / $14.71 / $19.61
| Facility | | $1.62 | $14.71 | $19.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.72 / $12.93 / $17.25
| Professional | | $1.72 | $12.93 | $17.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.93 / $13.93 / $28.87
| Facility | | $13.93 | $13.93 | $28.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.93 / $13.93 / $115.73
| Professional | | $13.93 | $13.93 | $115.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.65 / $12.23 / $16.42
| Professional | | $8.65 | $12.23 | $16.42 |