- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.35 / $10.35 / $26.60
| Facility | | $10.35 | $10.35 | $26.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.35 / $13.22 / $13.42
| Professional | | $10.35 | $13.22 | $13.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.57 / $29.78 / $33.43
| Professional | | $24.57 | $29.78 | $33.43 |
- 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
- $10.35 / $22.17 / $100.00
| Facility | | $10.35 | $22.17 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.39 / $17.73 / $29.56
| Professional | | $7.39 | $17.73 | $29.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.21 / $10.34 / $25.35
| Professional | | $6.21 | $10.34 | $25.35 |