- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.03 / $37.04 / $37.04
| Facility | | $0.03 | $37.04 | $37.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.04 / $37.04 / $37.04
| Professional | | $37.04 | $37.04 | $37.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.70 / $2.70 / $2.70
| Professional | | $2.70 | $2.70 | $2.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.08 / $26.97 / $26.97
| Facility | | $25.08 | $26.97 | $26.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.56 / $63.16 / $63.16
| Facility | | $0.56 | $63.16 | $63.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.24 / $23.05 / $25.30
| Professional | | $11.24 | $23.05 | $25.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.71 / $16.71 / $17.03
| Facility | | $16.71 | $16.71 | $17.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.39 / $16.71 / $22.48
| Professional | | $16.39 | $16.71 | $22.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.72 / $11.49 / $22.30
| Professional | | $8.72 | $11.49 | $22.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.00 / $135.76 / $135.76
| Facility | | $50.00 | $135.76 | $135.76 |