- 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
- $8.33 / $8.33 / $8.33
| Professional | | $8.33 | $8.33 | $8.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.76 / $41.30 / $41.30
| Facility | | $30.76 | $41.30 | $41.30 |
- 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
- $7.43 / $11.17 / $41.80
| Professional | | $7.43 | $11.17 | $41.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.72 / $22.72 / $23.16
| Facility | | $22.72 | $22.72 | $23.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.28 / $22.72 / $27.50
| Professional | | $22.28 | $22.72 | $27.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.73 / $12.08 / $22.63
| Professional | | $10.73 | $12.08 | $22.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.00 / $135.76 / $135.76
| Facility | | $50.00 | $135.76 | $135.76 |