- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.93 / $121.06 / $544.36
| Facility | | $58.93 | $121.06 | $544.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.50 / $3.50 / $144.63
| Professional | | $3.50 | $3.50 | $144.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.46 / $5.80 / $10.49
| Facility | | $4.46 | $5.80 | $10.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $3.02 / $3.02
| Professional | | $3.02 | $3.02 | $3.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $3.02 / $3.02
| Professional | | $3.02 | $3.02 | $3.02 |