- 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
- $5.81 / $5.81 / $12.29
| Professional | | $5.81 | $5.81 | $12.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.76 / $40.53 / $40.53
| Facility | | $30.76 | $40.53 | $40.53 |
- 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 / $25.30 / $51.04
| Professional | | $11.24 | $25.30 | $51.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.74 / $27.74 / $28.26
| Facility | | $27.74 | $27.74 | $28.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.48 / $27.74 / $27.74
| Professional | | $22.48 | $27.74 | $27.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.24 / $14.50 / $27.62
| Professional | | $11.24 | $14.50 | $27.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.00 / $135.76 / $135.76
| Facility | | $50.00 | $135.76 | $135.76 |