- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.47 / $1.61 / $2,730.60
| Professional | | $1.47 | $1.61 | $2,730.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.46 / $3.46 / $3.46
| Facility | | $3.46 | $3.46 | $3.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.94 / $3.46 / $3.46
| Professional | | $2.94 | $3.46 | $3.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.47 / $1.66 / $2.06
| Professional | | $1.47 | $1.66 | $2.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.47 / $1.47 / $1.47
| Professional | | $1.47 | $1.47 | $1.47 |