- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.53 / $12.53 / $32.22
| Facility | | $12.53 | $12.53 | $32.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.53 / $12.53 / $16.82
| Professional | | $12.53 | $12.53 | $16.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.94 / $36.07 / $40.28
| Professional | | $26.94 | $36.07 | $40.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.65 / $20.86 / $26.23
| Professional | | $20.65 | $20.86 | $26.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.53 / $26.85 / $100.00
| Facility | | $12.53 | $26.85 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.68 / $21.48 / $30.43
| Professional | | $8.68 | $21.48 | $30.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.52 / $21.48 / $30.05
| Professional | | $7.52 | $21.48 | $30.05 |