- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.74 / $3.74 / $16.53
| Professional | | $3.74 | $3.74 | $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
- $12.46 / $16.30 / $52.12
| Professional | | $12.46 | $16.30 | $52.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $15.12 / $17.28
| Professional | | $10.58 | $15.12 | $17.28 |
- 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 |