- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.78 / $5.78 / $14.87
| Facility | | $5.78 | $5.78 | $14.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.78 / $5.78 / $7.76
| Professional | | $5.78 | $5.78 | $7.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.48 / $16.64 / $18.68
| Professional | | $12.48 | $16.64 | $18.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.50 / $9.59 / $12.06
| Professional | | $9.50 | $9.59 | $12.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.78 / $11.38 / $100.00
| Facility | | $5.78 | $11.38 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.47 / $9.91 / $14.04
| Professional | | $3.47 | $9.91 | $14.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.47 / $8.43 / $12.51
| Professional | | $3.47 | $8.43 | $12.51 |