- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.48 / $12.48 / $12.48
| Facility | | $12.48 | $12.48 | $12.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.48 / $12.48 / $13.26
| Professional | | $12.48 | $12.48 | $13.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.65 / $133.31 / $133.31
| Professional | | $126.65 | $133.31 | $133.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.26 / $13.26 / $13.26
| Facility | | $13.26 | $13.26 | $13.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.26 / $276.57 / $1,206.04
| Professional | | $13.26 | $276.57 | $1,206.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.48 / $20.59 / $24.34
| Facility | | $12.48 | $20.59 | $24.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.00 / $13.00 / $15.60
| Professional | | $13.00 | $13.00 | $15.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.43 / $276.57 / $1,206.04
| Facility | | $215.43 | $276.57 | $1,206.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.43 / $340.91 / $1,206.04
| Professional | | $215.43 | $340.91 | $1,206.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.35 / $13.00 / $15.60
| Professional | | $12.35 | $13.00 | $15.60 |