- 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
- $16.52 / $16.52 / $20.65
| Professional | | $16.52 | $16.52 | $20.65 |
- 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
- $16.52 / $20.65 / $22.66
| Professional | | $16.52 | $20.65 | $22.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.76 / $14.62 / $32.72
| Professional | | $12.76 | $14.62 | $32.72 |