- 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
- $12.46 / $12.46 / $20.65
| Professional | | $12.46 | $12.46 | $20.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.16 / $22.46 / $44.97
| Professional | | $17.16 | $22.46 | $44.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $15.12 / $18.16
| Professional | | $10.58 | $15.12 | $18.16 |
- 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 |