- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.30 / $6.30 / $16.20
| Facility | | $6.30 | $6.30 | $16.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.30 / $6.30 / $8.46
| Professional | | $6.30 | $6.30 | $8.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.55 / $18.14 / $20.25
| Professional | | $13.55 | $18.14 | $20.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.33 / $10.43 / $13.11
| Professional | | $10.33 | $10.43 | $13.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.30 / $10.71 / $100.00
| Facility | | $6.30 | $10.71 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.78 / $9.61 / $15.30
| Professional | | $3.78 | $9.61 | $15.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.78 / $9.18 / $12.60
| Professional | | $3.78 | $9.18 | $12.60 |