- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.47 / $2.47 / $36.00
| Professional | | $2.47 | $2.47 | $36.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.80 / $2.80 / $16.97
| Facility | | $2.80 | $2.80 | $16.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.77 / $3.77 / $3.77
| Professional | | $3.77 | $3.77 | $3.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.33 / $3.32 / $5.53
| Facility | | $2.33 | $3.32 | $5.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.47 / $2.47 / $5.53
| Professional | | $2.47 | $2.47 | $5.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.33 / $3.32 / $5.53
| Facility | | $2.33 | $3.32 | $5.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.47 / $2.47 / $5.53
| Professional | | $2.47 | $2.47 | $5.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.47 / $2.62 / $11.36
| Professional | | $2.47 | $2.62 | $11.36 |