- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.87 / $141.25 / $174.60
| Facility | | $105.87 | $141.25 | $174.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.21 / $1.21 / $111.50
| Facility | | $1.21 | $1.21 | $111.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.69 / $15.69 / $19.62
| Professional | | $15.69 | $15.69 | $19.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.21 / $1.21 / $111.50
| Facility | | $1.21 | $1.21 | $111.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.69 / $18.00 / $19.62
| Professional | | $15.69 | $18.00 | $19.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.03 / $14.62 / $22.37
| Professional | | $9.03 | $14.62 | $22.37 |