- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.48 / $32.36 / $32.36
| Professional | | $7.48 | $32.36 | $32.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.43 / $12.68 / $19.21
| Facility | | $9.43 | $12.68 | $19.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.75 / $8.44 / $9.43
| Professional | | $6.75 | $8.44 | $9.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.43 / $11.36 / $19.21
| Facility | | $9.43 | $11.36 | $19.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.85 / $6.50 / $9.43
| Professional | | $5.85 | $6.50 | $9.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.90 / $3.90 / $8.94
| Professional | | $3.90 | $3.90 | $8.94 |