- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.56 / $10.56 / $27.14
| Facility | | $10.56 | $10.56 | $27.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.56 / $10.56 / $14.18
| Professional | | $10.56 | $10.56 | $14.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.07 / $30.39 / $34.10
| Professional | | $25.07 | $30.39 | $34.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.35 / $17.52 / $22.03
| Professional | | $17.35 | $17.52 | $22.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.56 / $22.62 / $98.60
| Facility | | $10.56 | $22.62 | $98.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.83 / $18.10 / $25.85
| Professional | | $6.83 | $18.10 | $25.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.33 / $15.38 / $25.85
| Professional | | $6.33 | $15.38 | $25.85 |