- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.90 / $11.90 / $11.90
| Facility | | $11.90 | $11.90 | $11.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.48 / $11.90 / $13.19
| Professional | | $8.48 | $11.90 | $13.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.46 / $25.46 / $25.46
| Facility | | $25.46 | $25.46 | $25.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.46 / $22.85 / $28.56
| Professional | | $14.46 | $22.85 | $28.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.13 / $14.33 / $100.00
| Facility | | $12.13 | $14.33 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.60 / $11.39 / $22.73
| Professional | | $7.60 | $11.39 | $22.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.55 / $23.21 / $29.89
| Facility | | $15.55 | $23.21 | $29.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.55 / $21.25 / $33.04
| Professional | | $15.55 | $21.25 | $33.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.95 / $29.56 / $34.78
| Professional | | $14.95 | $29.56 | $34.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.32 / $7.73 / $15.19
| Professional | | $5.32 | $7.73 | $15.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.66 / $12.66 / $12.66
| Professional | | $12.66 | $12.66 | $12.66 |