- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.71 / $10.71 / $27.54
| Facility | | $10.71 | $10.71 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.71 / $10.71 / $14.38
| Professional | | $10.71 | $10.71 | $14.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.03 / $30.83 / $34.43
| Professional | | $23.03 | $30.83 | $34.43 |
- 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
- $10.71 / $22.95 / $90.00
| Facility | | $10.71 | $22.95 | $90.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.58 / $18.36 / $26.01
| Professional | | $7.58 | $18.36 | $26.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.43 / $18.36 / $24.50
| Professional | | $6.43 | $18.36 | $24.50 |