- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.50 / $7.57 / $11.30
| Professional | | $1.50 | $7.57 | $11.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.60 / $6.29 / $10.47
| Facility | | $1.60 | $6.29 | $10.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.10 / $1.60 / $2.31
| Professional | | $1.10 | $1.60 | $2.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.75 / $8.52 / $8.52
| Professional | | $3.75 | $8.52 | $8.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.34 / $8.66 / $90.00
| Facility | | $5.34 | $8.66 | $90.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.56 / $10.30 / $15.84
| Professional | | $8.56 | $10.30 | $15.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.77 / $10.30 / $15.80
| Professional | | $8.77 | $10.30 | $15.80 |