- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.84 / $10.84 / $10.84
| Facility | | $10.84 | $10.84 | $10.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.73 / $10.84 / $10.84
| Professional | | $7.73 | $10.84 | $10.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.35 / $20.89 / $26.11
| Professional | | $13.35 | $20.89 | $26.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.88 / $13.06 / $60.00
| Facility | | $10.88 | $13.06 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.88 / $10.38 / $17.30
| Professional | | $5.88 | $10.38 | $17.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.84 / $20.18 / $22.69
| Facility | | $13.84 | $20.18 | $22.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.84 / $21.49 / $25.27
| Professional | | $13.84 | $21.49 | $25.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.53 / $27.78 / $31.68
| Professional | | $11.53 | $27.78 | $31.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.84 / $6.92 / $13.84
| Professional | | $4.84 | $6.92 | $13.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.53 / $11.53 / $11.53
| Professional | | $11.53 | $11.53 | $11.53 |