- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.09 / $12.09 / $31.09
| Facility | | $12.09 | $12.09 | $31.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.09 / $12.09 / $16.23
| Professional | | $12.09 | $12.09 | $16.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.00 / $34.79 / $38.86
| Professional | | $26.00 | $34.79 | $38.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.82 / $20.02 / $25.18
| Professional | | $19.82 | $20.02 | $25.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.09 / $20.55 / $82.03
| Facility | | $12.09 | $20.55 | $82.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.25 / $17.27 / $29.36
| Professional | | $7.25 | $17.27 | $29.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.27 / $17.27 / $17.27
| Facility | | $17.27 | $17.27 | $17.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.25 / $19.00 / $24.18
| Professional | | $7.25 | $19.00 | $24.18 |