- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.37 / $19.00 / $19.00
| Professional | | $13.37 | $19.00 | $19.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $6.26 / $10.74 / $10.74
| Professional | TC | $6.26 | $10.74 | $10.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.01 / $22.45 / $30.80
| Professional | | $14.01 | $22.45 | $30.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $7.26 / $12.21 / $17.68
| Professional | TC | $7.26 | $12.21 | $17.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.41 / $22.98 / $38.85
| Professional | | $14.41 | $22.98 | $38.85 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $7.06 / $13.83 / $18.63
| Professional | TC | $7.06 | $13.83 | $18.63 |