- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.81 / $10.81 / $10.81
| Facility | | $10.81 | $10.81 | $10.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.43 / $10.81 / $10.81
| Professional | | $10.43 | $10.81 | $10.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.19 / $11.58 / $15.63
| Professional | | $10.19 | $11.58 | $15.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.32 / $25.18 / $40.86
| Professional | | $17.32 | $25.18 | $40.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.81 / $11.46 / $25.51
| Facility | | $10.81 | $11.46 | $25.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.59 / $16.32 / $28.04
| Professional | | $10.59 | $16.32 | $28.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.42 / $26.42 / $100.00
| Facility | | $26.42 | $26.42 | $100.00 |