- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.00 / $2,942.76 / $5,692.86
| Facility | | $12.00 | $2,942.76 | $5,692.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.07 / $12.07 / $14.54
| Professional | | $12.07 | $12.07 | $14.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.00 / $12.00 / $12.07
| Professional | | $12.00 | $12.00 | $12.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.07 / $12.07 / $15.37
| Professional | | $12.07 | $12.07 | $15.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.07 / $12.07 / $13.46
| Professional | | $12.07 | $12.07 | $13.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.07 / $12.07 / $12.79
| Professional | | $12.07 | $12.07 | $12.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.49 / $11.49 / $11.49
| Professional | | $11.49 | $11.49 | $11.49 |