- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.28 / $10.28 / $26.44
| Facility | | $10.28 | $10.28 | $26.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.28 / $17.57 / $19.32
| Professional | | $10.28 | $17.57 | $19.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.12 / $29.60 / $33.04
| Professional | | $22.12 | $29.60 | $33.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.93 / $17.10 / $21.50
| Professional | | $16.93 | $17.10 | $21.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.28 / $22.04 / $77.00
| Facility | | $10.28 | $22.04 | $77.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.28 / $17.63 / $25.19
| Professional | | $7.28 | $17.63 | $25.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.17 / $14.98 / $25.19
| Professional | | $6.17 | $14.98 | $25.19 |