- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.33 / $5.33 / $16.53
| Professional | | $5.33 | $5.33 | $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 / $46.46
| Professional | | $12.46 | $12.46 | $46.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.21 / $23.85 / $47.75
| Professional | | $18.21 | $23.85 | $47.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $15.12 / $20.58
| Professional | | $10.58 | $15.12 | $20.58 |
- 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 |