- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.93 / $108.93 / $108.93
| Facility | | $108.93 | $108.93 | $108.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.21 / $1.21 / $114.80
| Facility | | $1.21 | $1.21 | $114.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.41 / $19.41 / $24.26
| Professional | | $19.41 | $19.41 | $24.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.21 / $1.21 / $114.80
| Facility | | $1.21 | $1.21 | $114.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.89 / $19.41 / $24.26
| Professional | | $16.89 | $19.41 | $24.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.64 / $14.62 / $27.27
| Professional | | $10.64 | $14.62 | $27.27 |