- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.62 / $5.62 / $17.59
| Professional | | $5.62 | $5.62 | $17.59 |
- 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 / $23.23
| Professional | | $12.46 | $12.46 | $23.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.00 / $24.88 / $105.99
| Professional | | $19.00 | $24.88 | $105.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $15.12 / $20.28
| Professional | | $10.58 | $15.12 | $20.28 |
- 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 |