- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.04 / $5.04 / $16.53
| Professional | | $5.04 | $5.04 | $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
- $6.61 / $8.26 / $12.46
| Professional | | $6.61 | $8.26 | $12.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $22.23 / $44.51
| Professional | | $16.98 | $22.23 | $44.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.52 / $15.12 / $20.58
| Professional | | $11.52 | $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 |