- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.52 / $327.52 / $406.79
| Facility | | $327.52 | $327.52 | $406.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.21 / $1.21 / $1.21
| Facility | | $1.21 | $1.21 | $1.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.13 / $32.21 / $40.27
| Professional | | $21.13 | $32.21 | $40.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.21 / $1.21 / $1.21
| Facility | | $1.21 | $1.21 | $1.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.13 / $32.21 / $40.27
| Professional | | $21.13 | $32.21 | $40.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.64 / $19.85 / $46.23
| Professional | | $10.64 | $19.85 | $46.23 |