- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.81 / $10.81 / $48.32
| Facility | | $10.81 | $10.81 | $48.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.76 / $8.76 / $10.81
| Professional | | $8.76 | $8.76 | $10.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.46 / $14.43 / $112.97
| Facility | | $10.46 | $14.43 | $112.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.32 / $4.32 / $12.50
| Professional | | $4.32 | $4.32 | $12.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.68 / $14.92 / $23.07
| Facility | | $12.68 | $14.92 | $23.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.80 / $14.71 / $15.73
| Professional | | $10.80 | $14.71 | $15.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.81 / $10.81 / $13.09
| Professional | | $10.81 | $10.81 | $13.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.81 / $10.81 / $48.32
| Facility | | $10.81 | $10.81 | $48.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.76 / $8.76 / $10.81
| Professional | | $8.76 | $8.76 | $10.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.49 / $8.84 / $21.36
| Professional | | $6.49 | $8.84 | $21.36 |