- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.63 / $52.68 / $326.14
| Facility | | $13.63 | $52.68 | $326.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.36 / $11.36 / $15.65
| Professional | | $11.36 | $11.36 | $15.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.36 / $11.36 / $11.67
| Professional | | $11.36 | $11.36 | $11.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.36 / $11.36 / $14.47
| Professional | | $11.36 | $11.36 | $14.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.36 / $11.36 / $49.38
| Professional | | $11.36 | $11.36 | $49.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.36 / $11.36 / $18.41
| Professional | | $11.36 | $11.36 | $18.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.90 / $14.90 / $14.90
| Professional | | $14.90 | $14.90 | $14.90 |