- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.56 / $72.76 / $72.76
| Facility | | $10.56 | $72.76 | $72.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.56 / $13.05 / $13.44
| Professional | | $10.56 | $13.05 | $13.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.07 / $30.39 / $34.10
| Professional | | $25.07 | $30.39 | $34.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.35 / $17.52 / $22.03
| Professional | | $17.35 | $17.52 | $22.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.56 / $22.62 / $100.00
| Facility | | $10.56 | $22.62 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.54 / $18.10 / $30.16
| Professional | | $7.54 | $18.10 | $30.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.33 / $10.55 / $25.85
| Professional | | $6.33 | $10.55 | $25.85 |