- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.14 / $161.38 / $311.54
| Facility | | $5.14 | $161.38 | $311.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.37 / $2.37 / $2.98
| Professional | | $2.37 | $2.37 | $2.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.37 / $2.37 / $2.46
| Professional | | $2.37 | $2.37 | $2.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.37 / $2.37 / $3.02
| Professional | | $2.37 | $2.37 | $3.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.37 / $2.37 / $8.23
| Professional | | $2.37 | $2.37 | $8.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.37 / $2.37 / $2.50
| Professional | | $2.37 | $2.37 | $2.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.97 / $1.97 / $1.97
| Professional | | $1.97 | $1.97 | $1.97 |