- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.82 / $13.82 / $35.53
| Facility | | $13.82 | $13.82 | $35.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.82 / $17.77 / $17.91
| Professional | | $13.82 | $17.77 | $17.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.82 / $39.78 / $44.64
| Professional | | $32.82 | $39.78 | $44.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.72 / $22.94 / $28.85
| Professional | | $22.72 | $22.94 | $28.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.82 / $29.61 / $100.00
| Facility | | $13.82 | $29.61 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.78 / $23.69 / $33.85
| Professional | | $9.78 | $23.69 | $33.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.28 / $27.64 / $33.85
| Professional | | $8.28 | $27.64 | $33.85 |