- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.07 / $21.00 / $3,598.78
| Facility | | $12.07 | $21.00 | $3,598.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.07 / $12.19 / $16.57
| Professional | | $12.07 | $12.19 | $16.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.25 / $19.53 / $37.21
| Facility | | $12.25 | $19.53 | $37.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.07 / $12.07 / $12.07
| Professional | | $12.07 | $12.07 | $12.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.39 / $12.07 / $12.07
| Facility | | $11.39 | $12.07 | $12.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.07 / $12.07 / $12.07
| Professional | | $12.07 | $12.07 | $12.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.07 / $12.07 / $13.28
| Professional | | $12.07 | $12.07 | $13.28 |