- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.78 / $24.78 / $3,140.34
| Facility | | $24.78 | $24.78 | $3,140.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.67 / $11.11 / $11.85
| Professional | | $10.67 | $11.11 | $11.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.50 / $11.87 / $33.84
| Facility | | $9.50 | $11.87 | $33.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.68 / $10.68 / $11.07
| Professional | | $10.68 | $10.68 | $11.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.68 / $10.68 / $85.00
| Facility | | $10.68 | $10.68 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.68 / $10.68 / $10.68
| Professional | | $10.68 | $10.68 | $10.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.68 / $10.68 / $10.68
| Professional | | $10.68 | $10.68 | $10.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.78 / $24.78 / $3,140.34
| Facility | | $24.78 | $24.78 | $3,140.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.67 / $11.21 / $14.66
| Professional | | $10.67 | $11.21 | $14.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.68 / $10.68 / $16.84
| Professional | | $10.68 | $10.68 | $16.84 |