- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.61 / $137.51 / $419.76
| Facility | | $12.61 | $137.51 | $419.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.27 / $12.27 / $12.27
| Professional | | $12.27 | $12.27 | $12.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $62.49 / $97.72 / $152.05
| Facility | | $62.49 | $97.72 | $152.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.72 / $10.72 / $11.36
| Facility | | $10.72 | $10.72 | $11.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.36 / $11.36 / $21.33
| Professional | | $11.36 | $11.36 | $21.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.68 / $21.73 / $100.00
| Facility | | $11.68 | $21.73 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.36 / $11.68 / $12.86
| Professional | | $11.36 | $11.68 | $12.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.36 / $11.36 / $11.36
| Professional | | $11.36 | $11.36 | $11.36 |