- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.60 / $9.60 / $10.94
| Professional | | $9.60 | $9.60 | $10.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,456.92 / $5,821.21 / $8,577.84
| Facility | | $5,456.92 | $5,821.21 | $8,577.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.40 / $12.40 / $12.40
| Facility | | $12.40 | $12.40 | $12.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.96 / $17.80 / $18.59
| Professional | | $14.96 | $17.80 | $18.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.40 / $13.00 / $16.73
| Professional | | $12.40 | $13.00 | $16.73 |