- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.56 / $402.23 / $402.23
| Facility | | $13.56 | $402.23 | $402.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.56 / $13.56 / $14.27
| Professional | | $13.56 | $13.56 | $14.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.27 / $14.27 / $14.27
| Professional | | $14.27 | $14.27 | $14.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.47 / $2.47 / $2.47
| Professional | | $2.47 | $2.47 | $2.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.00 / $14.98 / $33.07
| Facility | | $5.00 | $14.98 | $33.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.42 / $11.64 / $16.23
| Professional | | $5.42 | $11.64 | $16.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.42 / $11.64 / $16.23
| Professional | | $5.42 | $11.64 | $16.23 |