- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.45 / $10.41 / $10.41
| Professional | | $3.45 | $10.41 | $10.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.09 / $8.86 / $12.80
| Facility | | $5.09 | $8.86 | $12.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.38 / $11.72 / $12.80
| Professional | | $9.38 | $11.72 | $12.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.75 / $8.86 / $12.80
| Facility | | $3.75 | $8.86 | $12.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.70 / $3.00 / $10.71
| Professional | | $2.70 | $3.00 | $10.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.26 / $1.26 / $3.60
| Professional | | $1.26 | $1.26 | $3.60 |