- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.50 / $5.50 / $5.50
| Professional | | $5.50 | $5.50 | $5.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $8,511.38 / $77,624.71
| Facility | | $5,011.87 | $8,511.38 | $77,624.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $14.13 / $14.13
| Professional | | $14.13 | $14.13 | $14.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.18 / $13.18 / $16.60
| Professional | | $13.18 | $13.18 | $16.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.36 / $56.23 / $309.03
| Facility | | $32.36 | $56.23 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.59 / $12.59 / $12.59
| Professional | | $12.59 | $12.59 | $12.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.79 / $14.79 / $14.79
| Professional | | $14.79 | $14.79 | $14.79 |