- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.53 / $12.12 / $3,760.21
| Facility | | $10.53 | $12.12 | $3,760.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.53 / $10.54 / $12.65
| Professional | | $10.53 | $10.54 | $12.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.12 / $12.12 / $13.06
| Professional | | $12.12 | $12.12 | $13.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,921.89 / $2,332.31 / $3,137.71
| Facility | | $1,921.89 | $2,332.31 | $3,137.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.54 / $10.54 / $10.54
| Professional | | $10.54 | $10.54 | $10.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.54 / $10.54 / $10.54
| Facility | | $10.54 | $10.54 | $10.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.54 / $10.54 / $15.42
| Professional | | $10.54 | $10.54 | $15.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.96 / $10.54 / $11.90
| Professional | | $8.96 | $10.54 | $11.90 |