- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.62 / $5.62 / $16.53
| Professional | | $5.62 | $5.62 | $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 / $30.98
| Professional | | $12.46 | $12.46 | $30.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.25 / $25.15 / $46.71
| Professional | | $19.25 | $25.15 | $46.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.52 / $15.12 / $22.40
| Professional | | $11.52 | $15.12 | $22.40 |
- 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 |