- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.58 / $16.02 / $16.57
| Professional | | $13.58 | $16.02 | $16.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.63 / $18.63 / $18.63
| Professional | | $18.63 | $18.63 | $18.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.23 / $9.23 / $9.23
| Professional | | $9.23 | $9.23 | $9.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.35 / $16.02 / $21.28
| Facility | | $14.35 | $16.02 | $21.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.40 / $10.14 / $21.54
| Professional | | $6.40 | $10.14 | $21.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.40 / $8.78 / $13.76
| Professional | | $6.40 | $8.78 | $13.76 |