- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.05 / $6.05 / $16.53
| Professional | | $6.05 | $6.05 | $16.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.31 / $2.72 / $3.17
| Facility | | $1.31 | $2.72 | $3.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.46 / $12.46 / $24.26
| Professional | | $12.46 | $12.46 | $24.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.58 / $26.94 / $53.94
| Professional | | $20.58 | $26.94 | $53.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $15.12 / $17.86
| Professional | | $10.58 | $15.12 | $17.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $3,000.00 / $4,410.00
| Professional | | $2,500.00 | $3,000.00 | $4,410.00 |