- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.20 / $19.20 / $19.20
| Facility | | $19.20 | $19.20 | $19.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.20 / $19.20 / $19.20
| Professional | | $19.20 | $19.20 | $19.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.11 / $11.89 / $13.08
| Facility | | $10.11 | $11.89 | $13.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.89 / $11.89 / $11.89
| Professional | | $11.89 | $11.89 | $11.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.61 / $8,702.00 / $13,785.00
| Facility | | $22.61 | $8,702.00 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.23 / $21.42 / $21.42
| Professional | | $18.23 | $21.42 | $21.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.74 / $26.38 / $30.37
| Professional | | $25.74 | $26.38 | $30.37 |