- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.77 / $8.63 / $10.40
| Professional | | $6.77 | $8.63 | $10.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.65 / $28.65 / $28.65
| Facility | | $28.65 | $28.65 | $28.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.18 / $22.32 / $30.55
| Professional | | $20.18 | $22.32 | $30.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.65 / $28.65 / $28.65
| Facility | | $28.65 | $28.65 | $28.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.18 / $28.65 / $30.55
| Professional | | $20.18 | $28.65 | $30.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.82 / $13.44 / $22.37
| Professional | | $5.82 | $13.44 | $22.37 |