- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.02 / $12.02 / $2,818.38
| Facility | | $12.02 | $12.02 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $12.02 / $14.45
| Professional | | $12.02 | $12.02 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $10.47 / $10.47
| Professional | | $10.47 | $10.47 | $10.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.32 / $8.32 / $9.12
| Facility | | $8.32 | $8.32 | $9.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.02 / $12.02 / $12.02
| Facility | | $12.02 | $12.02 | $12.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $12.02 / $12.02
| Professional | | $12.02 | $12.02 | $12.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.02 / $12.02 / $12.30
| Facility | | $12.02 | $12.02 | $12.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $12.02 / $18.62
| Professional | | $11.48 | $12.02 | $18.62 |