- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.23 / $12.92 / $14.22
| Professional | | $6.23 | $12.92 | $14.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.03 / $21.45 / $28.65
| Facility | | $21.03 | $21.45 | $28.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.03 / $28.65 / $30.55
| Professional | | $21.03 | $28.65 | $30.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.58 / $21.03 / $28.65
| Facility | | $6.58 | $21.03 | $28.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.02 / $21.57 / $28.65
| Professional | | $14.02 | $21.57 | $28.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.41 / $8.66 / $12.80
| Professional | | $8.41 | $8.66 | $12.80 |