- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.02 / $10.02 / $25.78
| Facility | | $10.02 | $10.02 | $25.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.02 / $12.48 / $13.46
| Professional | | $10.02 | $12.48 | $13.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.56 / $28.85 / $32.22
| Professional | | $21.56 | $28.85 | $32.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.52 / $16.69 / $20.98
| Professional | | $16.52 | $16.69 | $20.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.02 / $21.48 / $100.00
| Facility | | $10.02 | $21.48 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.10 / $17.18 / $24.55
| Professional | | $7.10 | $17.18 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.01 / $10.02 / $24.55
| Professional | | $6.01 | $10.02 | $24.55 |