- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.04
| Facility | | $0.02 | $0.02 | $0.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.00 / $140.00 / $140.00
| Professional | | $140.00 | $140.00 | $140.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.71 / $2.71 / $3.60
| Professional | | $2.71 | $2.71 | $3.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.38 / $57.10 / $89.66
| Facility | | $48.38 | $57.10 | $89.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.84 / $59.73 / $59.73
| Professional | | $31.84 | $59.73 | $59.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.56 / $54.56 / $54.56
| Facility | | $54.56 | $54.56 | $54.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.09 / $11.36 / $11.54
| Professional | | $9.09 | $11.36 | $11.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.06 / $47.56 / $112.04
| Facility | | $26.06 | $47.56 | $112.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.16 / $14.45 / $39.53
| Professional | | $10.16 | $14.45 | $39.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.16 / $13.91 / $39.53
| Professional | | $10.16 | $13.91 | $39.53 |