- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.38 / $12.38 / $12.38
| Facility | | $12.38 | $12.38 | $12.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.38 / $13.74 / $15.62
| Professional | | $12.38 | $13.74 | $15.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.78 / $12.49 / $12.49
| Facility | | $11.78 | $12.49 | $12.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.49 / $12.49 / $12.49
| Professional | | $12.49 | $12.49 | $12.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.76 / $13.74 / $17.59
| Facility | | $4.76 | $13.74 | $17.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.49 / $12.74 / $15.61
| Professional | | $12.49 | $12.74 | $15.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.42 / $24.43 / $55.00
| Professional | | $19.42 | $24.43 | $55.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.99 / $14.99 / $14.99
| Professional | | $14.99 | $14.99 | $14.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.49 / $12.49 / $12.49
| Professional | | $12.49 | $12.49 | $12.49 |